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HX64066720 
RD651H181892     Lectures  on  tumors  t 


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GASTRIC  DERANGEMENTS 


HORSFORD'SACIU  PHOSPHATE. 


Unl  ke  all  other  forms  of  phosphorus  in  combination,  such  as  dilute 
phosphoric  acid,  glacial  phosphoric  acid,  neutral  phosphate  of  lime,  hypo- 
phosphites,  etc.,  the  phosphates  in  this  product  are  in  solution,  and  readily- 
assimilable  by  the  system,  and  it  not  only  causes  no  trouble  with  the 
digestive  organs,  but  promotes  in  a  marked  degree  their  healthful  action. 

In  certain  forms  of  dyspepsia  it  acts  as  a  specific. 

Dr.  H  R.  Merville,  Milwaukee,  Wis.,  says:  "  I  regard  it  as  val- 
uable in  the  treatment  of  gastric  derangements  affecting  digestion." 

Dr.  E.  Osborne,  Mason  City,  la.,  says:  "I  consider  it  a  valuable 
addition  to  the  remedies  in  use  for  the  relief  of  gastric  disorders  depend- 
ent on  enervation." 

Dr.  Albert  Day,  Superintendent  of  the  Washington  Home,  Bos- 
ton, says:  "  For  several  years  I  have  used  it  in  cases  of  alcoholism  and 
gastric  irritation.     It  is  of  special  value." 

Dr.  T.  G  CoMSTocK,  of  the  Good  Samaritan  Hospital,  St.  Louis, 
says:  '  For  soie  years  we  have  used  it  in  a  variety  of  derangements 
characterized  by  debility,  as  also  in  chronic  gastric  ailments.  It  is  ap- 
proved of,  unanimously,  by  the  medical  staff  of  this  Hospital." 

Dr.  G.  W.  Whitney,  Marshall,  Minn.,  says:  "I  have  used  it  in 
debility  of  the  nervous  system,  and  deranged  condition  of  all  the  secre- 
tory organs.     I  esteem  it  highly." 


Send  for  descriptive  circular.  Physicians  who  wish  to  test  it  will  be 
furnished  a  bottle  on  application,  without  expense,  except  express 
charges. 

Prepared  under  the  direction  of  Prof,  E.  N,  Horsford,  by  the 

HUMFOED  CHEMICAL  WORKS,  Providence,  R.  L. 


Beware  of  Substitutes  and  Imitations. 

<'A  ffTfO\:—Jif  nitre  the  tvovd  "■  Florsford's"  is  Printed  on  tlie  Inbel. 
All  otlii-rs  fire  »j>iirions.       Neiier  sold  in  hulk. 


LECTURES  ONTUMORS 


FROM    A 


CLINICAL  STANDPOINT. 


BY 


JOHN  B.  HAMILTON,  M.D.,  LLD., 

Prof essor  of  Principles  of  Surgery  and  Clinical  Surgery,  Rush  Medical 
College,  Chicago;  Professor  of  Surgery,  Chicago  Policlinic;  Sur- 
geon, formerly  Supervising  Surgeon-General,  U.  S.  Marine 
Hospital  Service;  Surgeon  to  Presbyterian  Hospital,  Chica- 
go; formerly  Professor  of  Surgery  in  Georgetown  Uiii- 
versity.  Surgeon  to  Providence  Hospital,  Etc.,  Etc. 


FOR    THE    USE    OF    STUDENTS. 


SECOND     EDITION. 


1892. 
GEORGE  S.  DAVIS, 

DRTROIT,  MICH 


Copyrighted  by 
GEORGE  S.  DAVIS. 

1893. 


Hi? 


PREFACE  TO  THE  SECOND  EDITION. 


The  fact  that  a  new  edition  of  this  book  has  been  called 
for  so  soon  after  its  first  appearance  is  a  gratifying  evidence 
that  it  was  needed,  and  that  it  measurably  met  the  wants  of 
those  for  whom  it  was  intended.  It  made  no  pretense  of 
being  exhaustive;  it  simply  dealt  with  the  elementary  prin- 
ciples of  the  subject,  and  was  intended  for  students.  Ex- 
tended references  to  more  elaborate  works,  it  was  thought, 
would  detract  from  its  simplicity  by  overloading,  and  thus 
tend  to  create  confusion  in  the  minds  of  beginners  in  the 
study. 

The  author  sincerely  thanks  the  reviewers  of  the  Medi- 
cal Press  who  gave  the  first  edition  such  a  very  cordial  re- 
ception, and  were 

"  To  its  virtues  very  kind 
And  to  its  faults  a  little  blind," 

and  he  sincerely  hopes  that  they  will  find  the  second  edition 
an  improvement  on  its  predecessor.  He  also  thanks  the  pub- 
lisher for  the  promptness  with  which  the  work  was  pub- 
lished after  the  manuscript  was  placed  in  his  hands. 

John  B.   Hamilton. 
United  States  Marine  Hospital, 
Chicago,  Dec.  31,  1891. 


PREFACE  TO  THE  FIRST  EDITION. 


I  have  been  repeatedly  asked  by  my  students  to  recom- 
mend a  book  on  Tumors,  in  English,  which  would  give  them, 
in  condensed  form,  a  practical  acquaintance  with  the  subject. 
I  was  obliged  to  say  I  knew  of  no  single  treatise  which  brought 
together  the  varieties  of  tumors  set  forth  in  our  present  no- 
menclature, and  gave  the  symptomatology  and  treatment. 

I  therefore  had  a  stenographer  take  the  lectures  as  they 
were  delivered,  and,  as  the  colloquial  form  has  thus  been 
preserved,  it  is  thought  to  bring  a  little  relief  to  the  hard- 
and-fast  lines  in  which  articles  on  tumors  are  usually  cast. 

Original  discovery  has  not  been  attempted;  but  with 
knowledge  of  the  fact  that  the  subject  is  always  considered 
a  bugbear  by  the  student,  the  lectures  only  aim  to  impart  the 
current  information  in  a  form  intended  to  fix  it  in  the  memory. 

The  experience  of  the  author  in  over  twenty  years  of 
surgical  practice  has  been  freely  made  use  of,  and  the  state- 
ments made  in  the  course  are  naturally  such  as  square  with 
the  clinically  observed  facts. 

For  the  last  ten  years  the  surgical  wards  of  the  Provi- 
dence Hospital  have  afforded  abundant  material  for  the  pro- 
secution of  the  clinical  study  of  tumors,  and  a  specimen  of 
every  tumor  removed  has  been  submitted  to  my  friend,  Prof. 
E.  M.  Schaeffer,  the  accomplished  histologist,  for  his  opinion 
and  remarks. 

In  a  short  time  it  is  proposed  to  supplement  this  vol- 
ume by  another  on  the  "Tumors  of  the  Regions,"  in  which 
the  operative  surgery  will  be  fully  considered. 

As  these  lectures  only  give  the  general  pathology,  clin- 
ical history,  and  treatment  of  neoplasms,  the  illustrations  are 
necessarily  limited  to  simple  types,  with  the  exception  of  the 
remarkable  specimens  inserted  as  surgical  curiosities. 

John  B.  Hamilton. 
924  McPherson  Sq.,  Washington  City, 
October  30,  1890. 


DEDICATION. 


This  book  is  respectfully 
DEDICATED  TO  THE  STUDENTS 

OF  THE 

Medical  Department 

OF 

Georgetown    University, 
To  whom  the  lectures  were  originally  delivered. 


LIST  OF  ILLUSTRATIONS. 

Frontispiece.  page 

Diagram  of  Ganglion 44 

Parasitic  Cyst 66 

Section  of  Molluscum  Fibrosum 79 

Unusual  Tumor  of  the  Thigh  (Front) 84 

(Back) 85 

Yaws 121 

Small  Round-celled  Sarcoma 127 

Giant-cell  Sarcoma 128 

Spindle-celled  Sarcoma 129 

Stroma  of  Carcinoma 135 

Diagram  representing  changes  taking  place  during  the 

invasion  of  connective  tissue  by  epithelial  columns.  136 
Case  of  Epithelioma,  starting  from  Cicatrix  of  Burn.  139 
Case  of  Scirrhus  of  Neck 141 


Representation  of  a  tumor  growing  nearly  the  full  length 
of  the  body.     From  the  Medical  Repository, 


INTRODUOTIOI^, 


The  purposes  of  diagnosis  usually  require  that 
the  microscope  be  employed  in  the  examination  of 
specimens.  The  student  wishing  to  perfect  himself  in 
the  knowledge  of  the  histology  of  tumors  should 
make  their  microscopical  examination  a  part  of  his 
course,  but  it  is  certain  that  nearly  constant  practice 
in  microscopical  technique  will  alone  produce  satis- 
factory results.  The  busy  and  often  overworked  prac- 
titioner has  sometimes  little  inclination  to  make  sec- 
tions and  mount  specimens,  and  oftener  has  no  time 
to  do  the  work.  It  thus  results  that  in  most  places 
there  are  within  reach  physicians  devoting  themselves 
especially  to  microscopy,  who  may  be  depended  upon 
for  furnishing  a  diagnosis  at  short  notice  and  much 
more  accurately  than  a  diagnosis  arrived  at  by  imper- 
fect methods  of  examination. 

The  appliances  necessary  for  the  histological  ex- 
amination of  tumors  are:  Jars  for  temporary  preserva- 
tion of  the  specimens;  preservative  fluids;  staining 
fluids;  microscope  slides  and  cover-glasses;  section 
cutter,  or  freezing  microtome;  watch-glasses;  a  special 
razor  for  cutting  sections;  forceps;  and  a  good  micro- 
scope. Expensive  stands  and  elaborate  stages  are  not 
necessary,  and  scarcely  desirable,  but  the  lenses  should 
be  good  and  should  well  define  the  edges  of  the  ob- 


ject.  Four  lenses,  i  inch,  ^  inch,  ^  inch,  and  ^^  inch, 
respectively,  will  be  quite  sufficient. 

The  easy  solubility  of  the  haemoglobin  causes  the 
fading  of  the  material  in  ordinary  preservative  fluids. 
Hamilton  (of  Aberdeen)  recommends  the  following 
composition: 

"  Make  a  saturated  solution  of  arsenious  acid  in 
water  by  boiling;  filter,  and,  when  still  warm,  mix 
together  equal  parts  of  this,  of  glycerin,  and  of  meth- 
ylated spirit.  It  is  well  to  mix  the  glycerin  and  arse- 
nious acid  solution,  to  heat  them,  and  afterwards  to 
add  the  spirit.  The  advantages  of  this  liquid  are  that 
it  keeps  the  color  of  the  organs  better  than  spirit,  it 
does  not  destroy  their  pliability,  and  it  is  a  good  pre- 
servative. If  several  organs  are  placed  in  one  jar 
they  should  be  separated  by  pieces  of  washed  linen 
cloth;  and  a  piece  of  the  same,  soaked  in  saturated 
solution  of  corrosive  sublimate,  should  be  placed  over 
them.  They  should  not  be  steeped  long  in  water 
before  being  placed  in  the  preservative;  it  is  usually 
sufficient  simply  to  wash  them.  Hearts,  livers,  kid- 
neys, lungs,  and  muscular  structures  keep  beauti- 
fully in  it." 

The  fluid  above  described  is  only  intended  for 
the  preservation  of  organs,  as  preliminary  to  section- 
cutting. 

Before  proceeding  to  cut  a  section  of  an  organ 
or  pathological  specimen  it  is  usually  placed  in  a 
hardening  fluid,  and  experience  has  shown  the  fluids 


—  3  — 
best  adapted  to  each  variety.    The  reagents  and  solu- 
tions necessary  are  as  follow:     (Altered  from  D.  J. 
Hamilton.) 

1.  Methylated  spirit. 

2.  Absolute  alcohol. 

3.  Miiller's  fluid. 

4.  Miiller's  fluid  and  spirit  (i  part  spirit  and  3 

parts  Miiller's  fluid). 

5.  Chromic  acid  (%  to  ^  per  cent,  solution). 

6.  Chromic  acid  and  spirit  (keep  in  the  dark). 

7.  Perosmic  acid  {}(  to  ys  per  cent.). 

8.  Gold  chloride  (^  to  2  per  cent.). 

9.  Picric  acid. 

10.     Decalcifying  and  hardening  solution  (Ruth- 
erford). 

The  solutions  have  the  following  formulge: 

3.     Miiller's  fluid. 

Potassic  bichromate. . .   45  grammes. 

Sodic  sulphate 20  grammes. 

Water 2  litres. 

M. 

10.     Rutherford's  fluid. 

Chromic  acid i  gramme. 

Water 200  c.  c. 

Then  add: 

Acid  nitric 2c.  c. 

Frequent   changes   of   the   fluids   are   necessary 
when  the  specimens  are  bloody,  and   friction  with  the 


—  4  — 
tissue  is  prevented  by  wrapping  each  piece  in  a  thin 
sterilized  linen  cloth  before  dropping  it  into  the  fluid. 
When  the  tissues  have  been  sufficiently  hardened  to 
enable  a  thin  section  to  be  cut,  the  section  after  cut- 
ting may  then  be  placed  in  an  appropriate  staining 
fluid. 

I  pass  over  the  technique  of  embedding  and  sec- 
tion cutting,  for  full  instructions  may  now  be  found  in 
almost  any  recent  work  on  pathology  and  in  the  differ- 
ent manuals  of  histology.  After  cutting  the  section, 
before  staining,  it  is  usually  dropped  into  a  watch- 
glass  containing  glycerin.  The  following  carmine 
solutions  are  in  common  use  as  staining  fluids: 

a.  Carmine gm.  4. 

Liquor  ammon  (fort) c.  c.  6. 

Water c.  c.  120. 

[Z>.  y.  Hamilton. 

Mix  the  carmine  into  a  paste  with  a  little  of  the 
water  in  a  mortar,  add  the  ammonia,  and  when  thor- 
oughly mixed,  the  remainder  of  the  water. 

b.  Carmine gm.0.5. 

Sodii  bibor. "      2.0. 

Aquse  destill c.  c.  100. 

M. 

\I).  J.  Hamilton. 

These  are  mixed  in  a  porcelain  evaporating  dish 
and  heated  to  boiling.  To  this  bluish-red  liquid, 
dilute  acetic  acid  (about  5  per  cent.)  is  added  till  the 


—  5  — 
color  changes  and  comes  to  be    more  like  that  of 
ammonia  carmine.     It  is  allowed  to  stand  for  twenty- 
four  hours,  decanted,  and  is  then  filtered.     A  drop  of 
carbolic  acid  is  added  to  preserve  it. 

c .  Picro-carmine 

Carmine gm.  i. 

\Ranvier. 

Dissolve  in  to  c.  c.  of  water  and  3  c.  c.  liquor 
ammonise  in  a  mortar,  add  this  to  the  200  c.  c.  cold 
saturated  solution  of  picric  acid.  Evaporate  either  on 
a  water-bath  or  by  exposure  to  the  air,  to  one  third, 
and  filter. 

d.  Picro-lithium  carmine 

Carmine gm.   2.50. 

\^Friedldnder. 

Dissolve  in  100  c.  c.  saturated  solution  lithium 
carbonate.  To  this  add  from  2  to  3  c.c.  of  a  saturated 
solution  of  picric  acid. 

There  is  also  an  alum-carmine  and  an  indigo- 
carmine  solution. 

To  stain  nuclei  logwood  is  used.  The  following 
is  given  by  D.  J.  Hamilton: 

Haematoxylene gm .  12 . 

Alum "•    50. 

Glycerin c.c.  65. 

Distilled  water c.c.  130. 

Boil,  and  while  hot  add  5  c.  c.  liquid  carbolic 
acid.     This  mixture  should  be  exposed  to  the  sun- 


—  6  — 

light  for  at  least  a  month  before  using.  This  stains 
nuclei  a  most  beautiful  blue  almost  instantaneously- 
after  application.  After  the  section  has  been  stained, 
it  may  be  placed  on  a  slide  and  examined. 

For  directions  for  making  museum  preparations, 
and  mounting  sections  in  permanent  form,  the  student 
is  referred  to  the  large  works  on  pathology  and  his- 
tology. It  is  impossible,  in  the  scope  assigned  to  these 
general  lectures,  to  undertake  to  give  directions  for 
examination  of  the  various  micro-organisms  and  for 
"smear"  preparations,  made  according  to  bacterio- 
logical methods. 


LECTURE  I. 

GENERAL  CONSIDERATIONS. 

We  are  about  to  consider  one  of  the  most  inter- 
esting subjects  in  the  whole  range  of  surgical  topics, 
and  when  we  think  how  often  the  patient's  knowledge 
of  his  chances  for  life  or  death  hangs  on  our  diag- 
nosis of  a  tumor,  whether  or  not  it  is  malignant,  we 
cannot  fail  rightly  to  regard  its  importance  as  second 
to  no  other.  If  we  will  examine  the  records  of  the 
civil  hospitals  in  this  and  other  countries,  we  will  find 
that  tumors  of  one  form  or  another  constitute  a  very 
large  proportion  of  all  the  cases  in  the  surgical  wards, 
outside  of  the  general  class  of  injuries. 

Technically  the  term  tumor  is  applied  to  a  neo- 
plasm only,  but  to  conform  to  the  existing  nomencla- 
ture, which  includes  cysts  and  hsematomata,  we  define 
a  tumor  to  be  a  generally  non-inflammatory,  abnormal 
swelling  of  some  of  the  tissues  of  the  body,  due  either 
to  retained  secretions,  extravasated  fluid,  or  new  form- 
ation. The  term  tumor,  surgically  applied,  means 
more  than  a  simple  swelling.  If  that  were  a  true 
definition,  the  colloquialism  which  makes  use  of  the 
word  tumor,  to  describe  the  projecting  end  of  a 
luxated  bone,  would  be  correct. 

I  have  said  non-inflammatory,  but,  our  Professor 
of  Pathology  will  doubtless  tell  you,  it  is  a  moot  point 
whether  or  not  certain  new  growths  have  their  origin 


in  the  exudation  thrown  out  in  the  inflammatory  pro- 
cess. True  inflammatory  products  are  temporary  in 
their  character,  and  the  part  in  which  they  are  seen 
has  passed  through  the  various  stages  of  inflamma- 
tion, hypersemia,  congestion,  and  exudation. 

A  tumor  rarely  terminates  by  a  natural  process. 
It  grows  until  removed  by  the  surgeon,  or  ulceration 
takes  place,  or  the  patient  is  poisoned  through  the 
lymphatics.  We  may  qualify  that  statement  by  say- 
ing that  a  tumor  may  occasionally  be  the  seat  of  an 
inflammation;  pus  is  formed  by  the  infection  and  death 
of  the  exudate  and  escapes,  the  tumor  consolidates 
and  contracts.  This  is  necessarily  rare  and  confined 
to  certain  non-malignant  growths. 

A  foreign  body  is  sometimes  mistaken  for  a 
tumor,  when  imbedded  in  the  tissues,  especially  when 
encapsulated.  In  one  of  the  European  Universities, 
where  the  code  duello  was  the  rule,  it  is  reported  of 
Dupuytren  that  a  medical  student  was  brought  to 
him,  who  said  he  had  a  tumor  which  had  been  grow- 
ing for  some  time.  He  thought  it  originated  from  an 
injury  received  in  a  duel.  A  conical  swelling  over 
the  buttock  was  the  outward  indication.  On  cutting 
into  the  tumor,  Dupuytren  found  the  point  of  a  sword. 

The  celebrated  Professor  South,  who  edited  a 
translation  of  Chelius,  relates  a  case  where  a  man  was 
in  bed  smoking  a  chalk  pipe,  and  while  asleep  received 
an  injury.  Time  passed  on,  and  a  swelling  super- 
vened.    He  consulted  surgeon    after   surgeon,    until 


■finally  it  was  decided  that  there  was  a  tumor  in  the 
■check,  which  should  be  removed.  Upon  examination 
it  was  discovered  that  a  piece  of  the  pipe-stem,'  one 
and  one-half  inches  long,  had  broken  off  in  the  cheek. 
In  the, Museum  of  the  Royal  College  of  Surgeons, 
London,  there  is  a  piece  of  glass  mirror,  which  was 
found  encysted  in  a  patient's  breast.  Dr.  Jos.  M. 
Toner,  of  this  city,  related  to  me  a  case  where  a  wax 
tube  (one  and  three-fourths  inches  in  length)  re- 
mained encysted  in  the  breast  for  one  year.  There 
are  numerous  examples  of  these  encysted  bodies 
which  are  likely  to  be  mistaken  for  tumors.  In  the 
Army  Medical  Museum,  at  this  Capital,  you  will  find 
a  specimen  deposited  by  myself,  consisting  of  exfoli- 
ated pieces  of  bone,  as  large  as  a  grain  of  rice  and 
upward.  These  I  found,  packed  together  and 
•encysted  in  the  thigh  of  a  patient.  From  the  history 
-of  the  case,  they  appear  to  have  been  the  bony  debris 
of  an  antecedent  abscess  of  the  periosteum. 

Chemistry  in  the  diagnosis  of  tumors  is  of  little 
use.  You  will  find  that  the  same  chemical  elements 
■enter  into  the  composition  of  a  tumor  as  into  the  body 
in  general.  With  the  microscope,  however,  you  have 
an  exact  means  of  diagnosis.  Very  incorrect  ideas 
prevail  about  the  microscope.  Some  apparently  be- 
lieve that  you  can  put  a  small  piece  of  tumor  under 
the  glass  and  at  a  glance  tell  just  what  the  specimen 
is.  You  cannot  do  anything  of  the  kind.  To  use  the 
microscope  intelligently  you  must  become  an  expert. 


It  is  not  enough  to  make  a  thin  section  and  place  it 
on  a  slide.  One  must  be  familiar  with  the  different 
forms  of  cells  and  animal  tissues;  and  its  use  requires 
constant  and  steady  practice.  Not  one  man  in  a 
hundred  can  demonstrate  the  bacilli  of  tuberculosis, 
or  the  comma  bacillus.  The  specimen  must  be  prop- 
erly treated  by  staining  in  order  to  render  the  bacilli 
visible.  This  staining  process  requires  a  special  train- 
ing. So  it  is  with  the  diagnosis  of  tumors.  A  man 
must  prepare  himself,  before  he  can  make  a  correct 
diagnosis.  Many  surgeons  content  themselves  with 
an  approximate  diagnosis,  or  bring  the  services  of  an 
expert  into  requisition,  and  here,  as  in  most  other 
schools,  opportunity  will  be  given  you  by  the  Profes- 
sor of  Histology  to  see  all  forms  of  tumors  under  the 
microscope.  I  have  made  this  statement  for  the 
simple  reason  that  a  man  giving  a  snap  diagnosis,  in 
making  up  his  opinion  of  a  tumor,  will  in  many  cases 
make  a-mistake,  especially  if  one  have  a  preconceived 
notion. 

Now  let  us  compare  morbid  growths  with  hyper- 
trophy. In  hypertrophy  there  is  no  departure  from- 
the  normal  structure.  The  hand  of  a  baseball  player, 
the  arm  of  a  blacksmith,  the  leg  of  a  danseuse,  are 
well  known  examples  of  hypertrophy.  These  hyper- 
plasia are  not  circumscribed.  We  see  the  same  in- 
crease of  growth  in  any  organ  called  ito  excessive  ac- 
tion for  a  considerable  time. 


NOMENCLATURE. 

The  ancients  recognized  three  grand  divisions  of 
tumors:  Tumores  secundum  naturam,  tumor es  supra 
naturam,  and  tumores  prceter  naturamj  but  in  the  be- 
ginning of  this  century  cUnicians  had  practically 
agreed  on  an  extremely  simple  classification  of  tumors 
by  which  they  were  divided  into  two  great  classes: 
Benign  and  malignant.  It  was  of  practical  utility. 
A  benign  tumor  was  one  which  did  not  directly  destroy 
life.  A  malignant  tumor  was  one  which,  sooner  or 
later,  destroyed  life.  It  was,  however,  found  that 
these  classes  shaded  into  one  another  so  that  some- 
times the  line  was  obliterated.  It  was  seen  that  a 
tumor  which  might  be  "  benign  "  in  the  beginning  be- 
came "  malignant  "  later  on.  The  advance  of  anatom- 
ical knowledge  and  of  knowledge  of  the  development 
of  cells  necessitated  subdivision.  Then  the  type  of 
structure  began  to  be  discussed,  and  there  was  in- 
vented the  term  "  homologous,"  meaning  similar  in 
morphological  structure  to  that  of  the  organ  in  which 
the  neoplasm  grows;  and  "  heterologous,"  meaning  a 
variation  from  the  normal  type  of  structure.  The 
degree  of  "  heterology  "  was  supposed  to  represent 
the  degree  of  malignancy.  This  proved  to  be  not  all 
the  truth.  Virchow  says:  "  One  cannot,  in  my  opin- 
ion, distinguish  these  tumors  according  to  the  tissues 
in  such  a  manner  that  tumors  which  inclose  in  them- 
selves certain  tissues  may  be  regarded  as  homeoplas- 


tic,  and  those  inclosing  other  types  of  tissues  hetero- 
plastic; on  the  contrary,  the  same  species  of  tumor 
may  be  in  one  circumstance  homologous  and  in  the 
other  heterologous — for  instance,  where  you  have  a 
hair  developed  in  the  stomach  or  in  a  vessel  wall,  or 
a  cartilaginous  tumor  growing  in  the  muscle;  if  you 
have  a  mucous  tumor  growing  in  the  bone,  such  a 
tumor  would  be  a  heterologous  tumor — that  is  to  say, 
a  growth  which  may  be  like  a  normal  structure,  but 
not  like  the  structure  in  which  it  is  located."  Broca 
has  used  the  terms  "  homomorphic  "  and  "  hetero- 
morphic  "  to  denote  similarity  or  dissimilarity  of 
structure.  The  modern  terms  homotopia  and  hetero- 
topia are  perhaps  more  correct.  Now  we  define 
hyperplasia  as  equivalent  to  the  term  neoplasm,  ex- 
cept that  a  neoplasm  must  be  circumscribed— that  is, 
all  growths  growing  from  a  parent  cell  from  the  edges 
of  the  tumor.  These  tumors  may  be  single  or  multi- 
ple; we  have,  for  instance,  multiple  fibromata;  these 
may  grow  all  over  the  body.  I  have  had  a  case  on 
which  I  think  there  must  have  been  twenty-five  tumors 
of  the  size  of  a  filbert— so  that  would  be  called  a  mul- 
tiple tumor.  The  large  cancerous  growths  are  usually 
single,  primarily.  So  much  for  the  general  nomencla- 
ture, but  I  shall  again  revert  to  this  topic  when  I 
speak  of  the  classification. 

A  tumor's  growth  varies  according  to  the  relative 
malignancy  of  the  tumor  —the  more  rapid  the  growth 
the  greater  the  malignancy.     A  carcinoma  (which  is  a 


—  13  — 

malignant  tumor)  attains  its  growth  and  destroys  the 
life  of  the  patient  comparatively  soon.  This  is  a  very 
interesting  point  in  the  diagnosis,  with  reference  to 
the  future  of  the  patient,  and  with  reference  to  an 
operation.  If  you  have  a  clear  case  of  fibrous  tumor, 
you  need  be  in  no  hurry  about  the  operation.  It  does 
not  destroy  life,  and  its  growth  is  comparatively  pain- 
less. In  a  case  of  cancer,  on  the  contrary,  its  growth 
is  rapid,  and-  surgical  interference  must  be  immediate 
if  success  is  to  be  hoped  for.  So  that  the  rapidity  of 
growth  of  a  tumor  is  a  guide  to  the  diagnosis  of  its 
variety,  and  a  sure  guide  to  the  therapeutics  of  the 
case.  In  regard  to  the  diagnosis  of  tumors,  the  con- 
figuration and  outward  appearance  give  you  some- 
thing of  an  idea  of  the  nature  of  the  case.  If  it  be  a 
chain  of  glands  which  is  involved,  such  as  those  of 
the  groin,  axilla,  or  neck,  and  there  be  a  clear  history  of 
tuberculosis,  in  that  case  you  know  that  it  is  not  a  ma- 
lignant tumor.  If  you  find  in  the  breast  small  nodules, 
that  feel  like  small  filberts,  or  hard  bodies  like  hazel 
nuts,  but  distinctly  connected  together  by  connective 
tissue,  then  you  probably  have  carcinoma.  Then  in 
the  cervix  uteri,  when  carcinoma  is  present,  it  is  com- 
mon to  find  nodules.  If  you  put  your  finger  on  the 
side  of  a  raspberry  you  have  almost  the  same  sense  of 
touch.  Palpation  in  -some  circumstances  does  not 
give  you  a  conclusive  conception  of'  the  actual  con- 
dition present.  It  may  have  progressed  to  the  stage 
of  abscess,  and  when  that  comes  you  simply  feel 
fluctuation  in  the  tumor. 


—  14  — 

The  size  of  the  tumor  is  another  element  to  take 
into  account.  I  should,  in  speaking  of  the  configura- 
tion of  the  tumor,  mention  that  lipoma  and  fibroma 
are  usually  conical,  and  may  weigh  anywhere  from  a 
few  grains  up  to  fifteen  or  twenty  pounds.  They  are 
sometimes  to  outward  view  as  conical  as  a  sugar  loaf. 
Such  tumors  frequently  have  a  long  pendulous  body, 
pedunculated.  Cancerous  tumors  are  generally  broad 
at  the  base,  and  not  very  movable.  The  mobility  of 
a  tumor  depends  very  largely  on  its  site.  If  it 
springs  from  the  bone  it  is  fixed  and  immovable.  If 
it  is  located  on  the  soft  parts  it  may  be  movable. 
Sometimes  it  is  located  directly  over  an  artery,  and 
may  then  be  mistaken  for  an  aneurism.  The  infiltra- 
tion of  the  skin  and  tissues  is  another  guide  to  the 
diagnosis  of  the  malignancy  or  benignancy  of  a  tumor. 
I  doubt  the  entire  propriety  of  the  term  "benign."  I 
do  not  think  a  tumor,  as  we  understand  the  term,  is 
meant  to  be  a  part  of  the  normal  frame;  in  that  sense 
all  tumors  are  malignant.  If  you  substitute  the 
French  term  bonne  nature,  or  good  natured,  for  benign, 
you  have  an  expression  of  sentiment  more  properly 
characterizing  those  tumors  which  do  not  destroy  life. 
The  infiltration  of  a  tumor  is  a  pretty  fair  measure  of 
its  malignancy.  We  have,  for  instance,  the  carcino- 
mata.  We  find  that  there  is  an  infiltration  or  projec- 
tion of  epithelium,  with  much  dense  fibrous  structure 
{stroma).  The  connective  tissue  is  separated  later- 
ally and  great  pain  produced.     The  intense  pain  of  a 


—  15  — 
cancerous  tumor  is  due  to  the  infiltration  of  the  tis- 
sues, precisely  as  if  a  foreign  body  were  driven  into 
the  flesh.  That  is  one  direct  reason  for  the  pain.  We 
do  not  find  infiltration  in  a  case  of  fatty  tumor.  It 
does  not  push  anything  but  the  skin  out  of  the  way. 
I  have  now  given  you  a  general  reason  for  painless 
and  painful  tumors,  excepting  those  composed  of 
nervous  tissue,  neuromata,  which  cannot  occur  with- 
>out  producing  great  pain.  You  would  suppose  that 
an  intra-ocular  tumor  would  be  very  painful,  whether 
malignant  or  not,  but  the  rule  holds  good  even  here. 
Then  the  extent  of  the  growth  of  the  tumor  alone  pro- 
duces great  pain.  I  remember  a  case  that  I  referred 
to  Professor  Burnett  some  years  ago.  (November, 
1883.)  In  that  case  there  was  no  pain.  The  patient 
was  unable  to  see,  and  there  was  a  growth  filling  the 
lower  part  of  the  posterior  chamber  of  the  globe. 
The  globe  was  extirpated,  and  the  patient  in  1890, 
5ix  years  later,  was  still  living  in  the  enjoyment  of 
good  health. 

Now  as  to  the  color  of  tumors.  They  are  usually 
situated  under  the  skin,  and  not  much  can  be  judged 
from  that.  There  are,  however,  certain  tumors 
characterized  by  pigmentous  infiltrations,  so  that  two 
forms  of  tumor  are  named  from  the  black  pigment 
(melano-carcinoma  and  melano-sarcoma).  The 
glandular  extension  of  tumors  depends  almost  entirely 
upon  their  malignancy.  I  will  take  cancers  of  the 
female  breast  as  an  example.  They  are  sooner  or  later 


—  i6  — 

followed  by  glandular  infection.  The  fluid  follows 
the  lymphatic  channels,  and  the  gland  itself  becomes 
infiltrated;  cancer  cells  effect  a  lodgment,  and  set  up 
a  new  growth  like  the  original  typical  structure  from 
which  they  sprang.  Now  as  to  recurrence:  You 
might  suppose  that  rapid  recurrence  would  be  evi- 
dence of  its  malignity.  Not  so.  You  might  remove 
a  polypus,  and  it  might  recur  in  a  few  days.  Polypus 
of  the  ear  may  recur  very  soon;  it  is  the  same  with 
uterine  polypi.  So  that  the  mere  recurrence  of  a 
tumor  is  no  evidence  of  its  malignity.  The  site  of  a 
tumor  is  variable;  you  may  have  one  in  almost  any 
structure  of  the  body.  The  ulceration  of  a  tumor  is 
a  matter  of  time.  In  the  case  of  a  fluid  tumor,  the 
pressure  of  the  clothing,  any  injury  to  the  skin,  may 
produce  ulceration.  In  the  case  of  other  tumors, 
where  an  inflammatory  process  has  gone  on,  there 
will  be  a  breaking  down  of  the  tissues,  due  to  inflam- 
mation, and  an  abscess  will  result.  The  vascularity 
of  these  tumors  is  considerable.  Sometimes  a  tumor 
will  be  supplied  by  a  blood  vessel  of  considerable  size, 
and  the  vessel  may  grow  proportionately  with  the 
tumor.  In  Professor  Frank  Hamilton's  Surgery,  he 
describes  a  case  where  he  was  operating  for  an  exten- 
sive tumor  of  the  neck.  He  was  explaining  to  the 
students  there  present  how  easy  it  was  to  separate  the 
tumor  from  the  tissues  so  that  no  haemorrhage  could 
result.  He  got  ready  to  lift  the  tumor  out,  when  a. 
gurgling  sound  was  heard,  and  a  gush   of  blood  fol- 


—  17  — 
lowed,  and  he  thought  he  had  lost  his  patient.  He 
found  that  a  large  artery  was  attached  to  the  tumor 
at  the  base— a  thing  that  could  not  have  been  discov- 
ered before.  He  relates  how  easy  it  is  to  be  surprised 
in  a  case  of  that  kind,  so  that  in  operations  you  .should 
in  all  cases  be  prepared  for  haemorrhage.  Remember 
that  the  venous  blood  vessels  are,  not  uncommonly, 
abnormally  distended.  In  a  sarcomatous  growth  you 
will  find  that  the  superficial  veins  are  very  greatly 
distended.  You  can  see  them  swelling  through  the 
skin,  almost  changing  the  configuration  of  the  tumor 
by  their  immense  size,  their  profusion,  and  tortuous 
course. 

For  our  knowledge  of  the  general  pathology  of 
tumors  we  must  depend  principally  upon  the  micro- 
scope Tumors  may  be  called  typical,  that  is,  com- 
posed of  typical  structure— where  they  are  formed  of 
normal  tissue.  For  instance,  the  fatty,  fibrous,  carti- 
laginous, and  lymphatic  tumors  are  typical. 

All  these  are  formed  from  structures  like  the 
type  from  which  they  are  named;  they  are  properly 
called  typical.  We  may  further  classify  them  accord- 
ing to  their  constituent  structure,  as  neuromata, 
lymphangeiomata,  angeiomata,  myomata,  etc.  Now 
the  term  Ai's/ou/  is  applied  to  this  class  of  tumors; 
that  is  to  say,  where  they  are  composed  of  a  single 
typical  structure.  A  neuroma  is  a  histoid  structure. 
Then  we  have  the  organoid,  where  there  is  more  than 
one  kind  of  .structure.     The  term  teratoid   is  applied 


to  the  highest  type  of  development  of  these  abnormal 
growths.  Also  the  "  combination "  tumor  of  Pro- 
fessor Gross,  which  consists  of  two  or  more  different 
structures,  as  naevoid,  cystic,  fatty,  fibrous,  calcareous,, 
or  osseous,  in  the  same  neoplasm.  It  is  not  an  infre- 
quent thing  to  find  several  kinds  of  cells  in  an  ovarian 
tumor. 

The  origin  of  tumors  is  sometimes  very  obscure. 
They  are  frequently  the  direct  result  of  an  injury. 
Polypus  of  the  nasal  passage  for,  example,  is  apt  ta 
follow  an  injury  to  the  nasal  bones.  The  so-called 
cryptorchids,  or  persons  whose  testicles  have  not 
descended  fully,  or  are  lodged  in  the  inguinal  canal, 
are  very  apt  to  have  carcinoma  or  sarcoma  in  the 
retained  testicles,  by  reason,  perhaps,  of  the  pressure 
of  the  abdominal  muscles;  especially  if  the  testicles 
be  partially  descended  so  that  they  are  lodged  in  the 
inguinal  canal.  In  regard  to  the  non-traumatic  origin 
of  a  tumor,  we  have  the  cell  theory  of  Schwann,  by 
which  the  "  caudate  corpuscles  "  were  the  supposed 
progenitors  of  the  fibres  of  connective  tissue.  That 
is  the  original  theory  on  which  all  modern  cellular 
pathology  is  based.  Miiller  then  followed  with  a 
study  of  morbid  growths.  Johannes  Miiller,  you  no 
doubt  recollect,  was  the  originator  of  the  term  "  con- 
nective tissue."  Then  Vogel  started  the  dyscrasia 
theory.  That  is  the  theory  that  the  blood  alone  is 
principally  affected;  but,  in  fact,  the  solids  as  well  as. 
the  blood  are  affected.     Then  the  theory  of  "consti- 


—  19  — 

tutional    taint;"  that   is,  that   ail    cancerous  growths 
depend  upon  constitutional  taint,  which  involves  the 
supposition    of   congenitally   defective   cells       Then 
came  Virchow  (still  living,  in  this  year  of  our  Lord 
1892,  and  at  this  time  as  active  as  ever),  who  by  the 
production   of    his  immortal  cellular  pathology  laid 
down  clear  lines  for  the  study  of  abnormal  growths 
His  later  work  on  tumors  gave  a  classification  which 
has  been  adhered  to  for  a  quarter  of  a  century  almost 
without  change.     Virchow  adopted  the  law  of  Miiller 
"which  is  in  effect  that  the  substance  of  all  tumors 
has  Its  counterpart  in  some  tissue  existing  normally 
m  embryonic  or  after  life."     Cohnheim,   the  pupil  of 
Virchow,  who  died  in  August,  1884,  believed  that    al 
tumors  are  congenital.     They  may  exist  in  all  forms 
and   are  simply,   while    undeveloped,    stored    up   for 
future  use,  and  remain  latent  until  the  conditions  are 
favorable  for  the  formation  of  a  new  growth       Then 
we  have  the  abnormal  "nerve  influence"  theory  that 
the  cell,   by  reason  of  some  chemical  change  in  its 
structure,  begins  the  generation  of  an  abnormal  brood- 
but  an  atypical  cell  cannot  produce  a  healthy  cell     It 
IS    impossible,  within    the   intended   scope   of   these 
elementary  lectures,  even  to  glance  in  passing  at  the 
various  ingenious  theories  that  have  been  propounded 
on  the  origin  of  tumors,  and  we  cannot  to-day  satis- 
factorily explain  that  indefinable  factor  in  their  pro- 
duction which  we  term  individual  susceptibility       We 
cannot  understand,  for  example,  why  one  of  a  dozeca 


shoemakers,  each  pounding  a  piece  of  sole  leather  on 
his  thigh,  should  have  a  sarcoma  of  traumatic  origin, 
and  all  the  others  escape.  So,  gentlemen,  you  need 
not  fear  but  there  are  plenty  of  unsolved  problems  to 
engage  your  highest  powers. 


LECTURE  II. 

CLASSIFICATION. 

In  the  preceding  lecture,  I  briefly  referred  to  the 
classification  of  tumors.  I  do  not  pretend  to  defend 
the  classification  on  which  I  shall  base  the  description 
of  these  tumors.  In  fact,  I  am  convinced  that  the 
classification  is  inaccurate,  and  that  it  should  be 
changed.  Why,  then,  you  naturally  say,  do  you  use  it? 
I  answer,  because  it  is  the  nomenclature  and  classi- 
fication adopted  some  years  ago  by  the  Royal  College 
of  Physicians  of  London  and  the  American  Medical 
Association.  American  physicians  had  a  voice  in  the 
'  Committee  that  drew  up  the  nomenclature,  at  its  last 
revision,  and  I  adhere  to  it  simply  for  the  purpose  of 
uniformity.  I  am  confident  that,  in  many  respects, 
this  classification  will  be  changed.  My  dear  friend, 
Professor  Gouley,  of  New  York,  in  one  of  the  most 
learned  works  produced  in  any  language  on  the  sub- 
ject of  medical  nomenclature,  says  of  Virchow's  classi- 
fication:* "The  high  reputation  of  this  great  master 
in  patho-anatomy  has  caused  his  nomenclature  and 
classification  of  tumors  to  be  largely  accepted  by  the 
profession  without  question.  This  classification  an- 
swered a  good  purpose  twenty-five    years   age,    and 


*  Diseases  of  Man:  their  Nomenclature,   Classification, 
and  Genesis,  New  York,  1888,  page  334. 


was  a  forward  step,  but  the  advances  since  made  in 
patho-histology  forbid  its  continued  use.  Neverthe- 
less, there  are  many  physicians  and  surgeons  who  still 
adhere  to  this  arrangement  of  tumors.  In  the  present 
light  of  science,  probably  no  one  sees  better  than 
Professor  Virchow  the  faults  of  this  as  well  as  of  all 
other  classifications,  and  if  his  occupations  should 
permit  him  to  undertake  its  reconstruction,  he  would 
doubtless  do  so  consistently  on  the  anatomical  basis 
which  does  not  abrogate,  but  rather  enforces,  Miiller's 
law.  He  would  probably  abandon  the  word  tumor, 
and  reject  the  hiiematomata,  and  also  the  cysts.  He 
would  drop  the  terms  histoid  and  organoid,  and  place 
the  teratoid  growths  under  the  caption  terata,  and 
make  a  very  different  disposition  of  the  mixed  growths 
©f  his- fourth  group."  Cornil  and  Ranvier,  in  propos- 
ing their  classification,  say  that  their  aim  has  been  "  to 
treat  simply  from  the  histological  pmnt  of  view,  and 
we  have  therefore  included  under  the  head  of  inflam- 
mation and  haemorrhage  what  seemed  to  us  to  rightly 
belong  to  them,  blood  tumors;  hygromata  for  example. 
We  also  think  we  have  a  right  to  reproach  Virchow 
with  having  invented  new  words,  drawn  from  gross 
physical  characters,  whereby  to  designate  certain 
tumors,  instead  of  employing  words  representative  of 
the  tissue.  Thus,  he  uses  the  word  psammoma  to 
signify  a  tumor  of  the  meninges,  because,  it  contains 
calcareous  granules  similar  to  fine  sand,  and  the  word 
glioma  is  applied  to  tumors  of  the  brain,  because  they 


—  ^2>  — 
are  of  a  consistency  analagous  to  glue.     He  thus  de- 
parts from  the  classification  which  Miiller's  law  sug- 
gests, and  which  we  intend  to  follow  absolutely." 

There  is  no  denying  the  impeachment  in  the  in- 
stances cited,  but  Gouley  has  pointed  out  that  the 
authors  are  themselves  inconsistent  in  many  instances. 

Cornil  and  Ranvier,  however,  admit  that  no  an- 
atomical classification  can  serve  to  determine  the 
■degree  of  the  gravity  of  a  tumor,  and  it  must  be  ap- 
parent that  the  correct  classification  can  only  follow 
positive  and  unchanging  facts  of  histogenesis.  Re- 
cent research  has  shown  us  positively  that  certain 
forms  of  tumors  are  due  to  the  presence  of  a  specific 
micro-organism,  and  that  a  great  many  of  them  at  the 
next  revision  must  therefore  be  taken  from  the  class 
in  which  they  are  now  arbitrarily  placed  by  our 
nomenclature  I  many  particularly  mention  tubercle, 
lupus,  syphilitic  gumma,  and  leprosy. 

I  trust,  therefore,  that  you  will  take  our  nomen- 
clature as  an  arbitrary  one,  subject  to  decennial  re- 
vision, as  we  now  revise  the  PharmacopiKia;  and  bear 
in  mind  that  we  already  have  considerable  material 
for  the  Committee  of  Revision.  Every  man  cannot 
have  his  own  classification,  because  there  would  then 
be  no  uniformity  of  terms  in  medical  literature. 


CLASSIFICATION    OF   TUMORS,    COMPREHEND- 
ING  MALIGNANT  NEW  GROWTHS,   NON- 
MALIGNANT  NEW  GROWTHS, 
AND  CYSTS.* 

CLASSES. 

I.     Extravasation  Tumors. 
ir.     Transudation    and    Exudation 

Tumors.  )■  CystJ 

III.  Retention  Tumors.  I 

IV.  Proliferation  Tumors.  j 
Class  J. — Extravasation  Tumors. 

I.     Hsematoma  :     Synonym,  blood- tumor. 

(7.     Cystiform. 

d.     Parenchymatous.. 

c.     Polypoid. 

Class    II. — Transudation    and    Exudation 
Tumors. 

1.  Hygroma:       Synonym,    watery    tumor,    or 

dropsy. 

2.  Dropsy  of  bursse  mucosae. 

3.  Proliferating  hygroma  of  bursse  mucosae. 

4.  Ganglion. 


[In  deference  to  the  needs  of  the  various  registration 
authorities,  a  distinction  has  been  made  in  the  general  and 
local    tables    between    malignant    and    non-malignant    new 

growths.     The  tumors  are,  however,  here  classified  accord- 

01 

*  From  the  last  revision  of  the  nomenclature  of  diseases 
of  the"  Royal  College  of  Physicians. 


Class  III. — Retention  Tumors,  or  Cysts. 

1.  Retention  in  loco  formationis. 

a.  Ranula. 

b.  Parovarian  cyst. 

c.  Wen:  Synonym,  sebaceous  cyst,  or  tumor. 

d.  Mucocele. 

2.  Retention  in  loco  distante. 

Class  IV. — Proliferation  Tumors. 
I.     Fibroma:     Synonym,  fibrous  tumors. 

Varieties: 
a.     Diffuse. 

I.     Elephantiasis. 
h.     Papillary. 

c.  Polypoid:     Synonym,  fibrous  polypus. 

I.     Molluscum  fibrosum. 

d.  Tuberous. 

I.     Epulis  in  part. 

e.  Bony. 
/.     Keloid. 

ing  to  their  mode  of  origin  and  their  structure  Such  a 
classification  involves,  in  certain  cases,  the  association  under 
one  head  of  malignant  and  non-malignant  growths,  as,  for 
instance,  under  Sarcoma.  To  facilitate  returns  under  the 
general  tables,  the  malignant  growths  are  here  marked  by 
two  asterisks;  the  names  which  include  both  kinds  of 
growth,  by  one.  The  classification  of  tumors,  to  be  com- 
plete, must  include  cysts  as  well  as  new  growths.  The 
cysts  are  accordingly  introduced,  but  in  italics;  and  should 
be  returned  severally  among  the  local  affections  of  organs.] 


—     26    — 

2.     Lipoma:     Synonym,  fatty  tumor. 
*3.     Myxoma:     Synonym,  nrucous  tissue  tumor. 

4.  Chondroma:    Synonym,  cartilaginous  tumor. 

Varieties: 

a.  Ecchondrosis. 
*b.  Enchondroma. 
*c.     Osteoid  Enchondroma. 

5.  Osteoma:     Synonym,  bony  tumor. 

Varieties: 

a.  Exostosis. 

b.  Hyperostosis. 

c.  Osteophyte. 

d.  Odontoma. 

6.  Psammoma:     Synonym,  brain-sand  tumor. 

7.  Melanoma:      Synonym,    pigment-tumor    of 

meninges. 

8.  Myoma:     Synonym,  muscle-tissue  tumor. 

Varieties: 

Myo-fibroma:  Synonym,  fibroid  tumor  of 
uterus. 

Striped  muscle  tumor:  Synonym,  rhabdo- 
myoma. 

9.  Neuroma:     Synonym,  nerve-tissue  tumor. 
10.     Adenoma:     Synonym,  glandular  tumor. 

a.     Mucous  polypus. 

/'.     Chronic     mammary    tumor:       Synonym, 

adenoid  tumor. 
c.     Molluscum  contagiosum. 


—    27    — 

IT.     Dermoid  cyst. 

12.  Angeioma:     Synonym,  blood-vessel  tumor. 

a.  Simple:     Synonym,  teleangeiertasis. 

b.  Cavernous:     Synonym,  naevus. 

1.  Arterial. 

2.  Venous. 

3.  Mixed. 

13.  Papilloma:     Synonym,  warty  tumor. 

a.  Wart. 

b.  Mucous  tubercle. 

c.  Condyloma. 

d.  Urethral  caruncle. 

*i4.     Glioma:     Synonym,  neuroglia  tumor. 
15.     fGranulation  tumors. 

Varieties: 

a.  Simple. 

b.  Lupus. 

c.  Gumma. 

d.  Lepra  Arabum,  or  elephantiasis  Graeco- 

rum. 

e.  Yaws . 

/.     Glanders . 
g.     Farcy . 
h.     Tubercle. 

*i6.     Lymphoma:      Synonym,      lymphatic-tissue 

tumor,  including  lymphadenoma. 
*i7.     Sarcoma. 


f  Due  to  infective  organisms. — J.  B.  H. 


—     28     — 

Varieties: 

a.  Round-celled. 

I).  Spindle-celled. 

c.  Melanotic. 

d.  Myeloid:       Synonym,     sarcoma     giganto- 

cellulare. 

I.     Epulis,  in  part. 

8.     Carcinoma:     Synonym,  cancer. f 

Varieties: 

a.  Epithelioma. 

Sub-variety:     Rodent  ulcer. 

Note. — Chimney-sweeper's  cancer  is  to  be  re- 
turned under  epithelioma. 

b.  Scirrhus. 

c.  Medullary. 
(/.  Melanotic. 

e.  Osteoid. 

/.     Cylindroid:     Synonym,  adenoid. 
g.     Colloid:     Synonym,  reticular   or   alveolar 
cancer. 

Syphilis. 

1.  Primary:     State  the  part  affected. 

2.  Constitutional:     State  if  congenital. 

a.     Inflammatory  and  "| 

exudative. 
,      r^  ^  Of  parts  of    body  ac 

0.     Gummatous.  I  ^  ■' 


c.  Ulcerative    and 

destructive.  | 

d.  Cicatricial .  J 


r       cording  to  order  of 
local  disease. 


t  See  page  129. 


—    29    — 


I.     Grey. 


Tubercle. 

Simple. 
Inflammatory. 
Ulcerative  and 

destructive. 
Retrograde  and 

cicatricial. 


2.  Yellow. 


Simple. 
Inflammatory. 
Ulcerative  and 

destructive. 
Retrograde  and 

cicatricial. 


1 


I    Of  parts  of   body  ac- 

I       cording  to  order  of 

local  disease. 


Of  parts  of  body  ac- 
cording to  order  of 
local  disease. 


LECTURE  III. 

EXTRAVASATION  TUMORS-H/£MATOMA— TRAN- 
SUDATION AND  EXUDATION  TU- 
MORS—HYGROMA. 

The  only  one  of  the  extravasation  tumors  is  the 
hsematoma,  or  blood  tumor.  We  have  three  varieties 
— cystiform,  parenchymatous,  and  polypoid.  We  have 
first  the  haematoma  auris — that  is,  the  blood  tumor  of 
the  cartilage  of  the  ear.  This  you  have  in  the  insane 
more  frequently  than  in  any  other  class — hence  it  is 
usually  called  the  "insane  ear."  It  consists  partly  of 
extravasated  blood  between  the  perichondrium  and 
the  cartilage,  is  occasionally  found  in  the  sane,  and  is 
supposed  to  be  due  to  general  cerebral  congestion. 
Then  we  have  pelvic  hsematoma,  or  hsematoma  proper. 
We  may  have  this  when  the  blood  is  infused  in  the 
pouch  between  the  rectum  and  the  uterus.  Then 
haematoma  pudendse,  situated  in  the  vulva,  and  gen- 
erally coming  on  after  labor.  Then  hsematoma  scrotal. 
Then  hsematoma  of  the  cord. 

Pelvic  Hamatoma.  Strictly  speaking,  this  is  not  a 
tumor,  but  as  the  classification  puts  it  in  this  place,  we 
will  now  consider  it.  It  is  frequently  taken  for  pelvic 
cellulitis.  Now  remember  that  pelvic  cellulitis  is  an 
inflammation  of  the  connective  tissue  of  the  pelvis, 
and  haematoma  is  first  due  to  the  rupture  of  a  vein  or 
veins  between  the  ovary  and  the  Fallopian  tube,  in 


—  31  — 
the  broad  ligament  of  the  uterus,  and  takes  place  most 
frequently  after  confinement.  It  comes  with  a  sharp 
pain  generally,  but  sometimes  there  is  not  much  pain. 
Very  rarely  there  is  a  chill,  whereas  in  cellulitis  the 
disease  is  ushered  in  with  a  marked  and  distinct  chill 
(rigor).  Now  if  we  look  at  the  anatomical  structure 
of  heematoma,  we  find  that  the  blood  flowing  out 
pushes  one  or  more  of  the  coverings  of  the  broad 
ligament  before  it  until  the  tumor  is  gradually  formed. 
It  pushes  aside  the  pelvic  fascia,  presses  upon  the 
vagina,  or  rectum,  and  then  we  have  what  is  called 
pelvic  hsematocele. 

It  is  not  proper  to  speak  of  haematometra  as  a 
tumor,  because  of  the  damming  iip  of  the  blood  in 
the  uterus  from  an  imperforate  hymen,  as  it  is  simply 
retention  of  the  blood.  When  we  have  pelvic  hgema- 
toma  it  is  due  to  rupture  of  the  blood-vessels  from 
external  or  internal  violence.  The  first  symptoms  are 
those  of  internal  haemorrhage  in  general — a  blanched 
appearance,  white  lips,  weakness  and  debility,  rapid 
pulse,  watery  condition  of  the  blood,  and  great  thirst. 
After  a  while  this  effused  blood  becomes  encysted  by 
a  false  "  membrane,"  called  the  limiting  fibrin.  Then 
one  of  two  things  happens:  Either  this  blood  clot 
softens,  becomes  infected,  and  degenerates  into  pus,  or 
it  becomes  absorbed  and  taken  up.  In  either  case  there 
is  a  subsidence  of  the  tumor.  The  surgeon  rarely 
sees  a  case  until  after  coagulation  has  taken  place; 
for  this  blood  does  not  remain  fluid,  but  by  reason 


—  32  — 

of  the  pressure  upon  it,  or  the  density  of  the  tissue 
surrounding  it,  becomes  coagulated,  slowly  but  surely. 
Then  after  a  while  a  tumor  is  formed.  Very  often  an 
ovarian  tumor  is  suspected.  The  question  will  then 
arise  as  to  the  differential  diagnosis.  As  I  told  you, 
the  history  of  the  case  will  afford  pretty  clear  indica- 
tions— the  absence  of  the  initial  chill,  the  cessation  of 
pain  (for  the  pain  of  haematomata  does  not  usually 
continue);  the  blood  slowly  coagulates,  and  it  is  a 
painless  swelling.  In  this  case  we  frequently  have  a 
complete  anteversion  of  the  uterus,  as  the  blood 
pushes  the  uterus  forward.  In  cellulitis  the  uterus  is 
not  necessarily  displaced,  so  that  in  making  a  vaginal 
examination  you  will  find  that  the  swelling  is  uniform, 
whereas  in  hsematoma  there  is  a  soft  tumor  situated 
just  behind  the  cervix,  in  the  cul  de  sac.  In  this  case 
there  is  no  fever,  while  in  cellulitis  there  is  fever. 
Now;  you  say,  how  can  we  make  a  diagnosis  between 
pelvic  haematoma  and  hsematometra  ?  The  history  of 
the  case,  and  the  imperforate  hymen  or  impervious 
cervical  canal,  would  show  you  the  difference,  and 
you  could  probably  tell  at  once  what  was  the  matter. 
There  is  another  point  of  difference  between  haema- 
toma—pelvic  haematoma— and  pelvic  cellulitis,  in  this, 
that  usually  the  swelling  does  not  materially  increase 
in  haematoma  after  the  tumor  is  formed.  Prognosis: 
The  simple  form  of  haematoma  has  a  tendency  to  re- 
covery, but  the  recovery  is  always  slow.  Sometimes 
the  tumor  points  in  the  vagina  or  rectum,  rupturing 


—  33  — 
the  tissue  of  those  organs  and  making  its  appearance 
externally.  Another  symptom  of  pelvic  tumors,  com- 
mon to  all  where  they  press  upon  the  rectum,  is  spas- 
modic, violent  tenesmus.  Sometimes  we  have  a  very 
severe  inflammation  of  the  rectum  due  to  mechanical 
pressure. 

Pelvic  hsematoma,  coming  on  in  the  male  or 
female  after  an  injury,  does  not  materially  differ  from 
the  form  already  described,  except  that  in  such  cases 
you  have  a  clear  history  of  the  injury.  If  the  disease 
is  not  recognized,  and  surgical  interference  is  not 
made  at  this  point,  there  will  be  recurrence,  with  ali 
the  disastrous  consequences  which  follow  septicaemia 
or  saprsemia,  not  from  coagulated  blood,  but  from 
blood  that  has  broken  down  and  from  the  formation 
of  pus.  In  very  rare  cases  these  tumors  may  origin- 
ate spontaneously.  When  we  have  hsemophiles,  or 
persons  having  a  tendency  to  haemorrhage  in  general, 
the  blood  does  not  readily  coagulate,  death  is  very 
speedy,  and  it  occurs  from  syncope  due  to  interna! 
haemorrhage.  The  length  of  time  the  patient  may 
live  will  vary,  but  usually  depends  upon  the  amount 
of  blood  poured  out.  I  once  saw  a  case  of  rupture  of 
the  spleen  where  that  organ  was  torn  directly  across. 
There  was  no  external  wound.  The  man  lived  two  or 
three  hours.  Upon  his  death,  on  opening  the  abdo- 
men, a  clot  of  blood  was  found  filling  the  entire  cavity; 
so  that  the  man  lived  an  unusually  long  time,  consid- 
ering the  amount  of  blood  lost. 

3  WW 


—  34  — 
Treatment :  The  first  indication  is  rest  in  a  re- 
cumbent position.  This  is  the  primary  indication. 
Then,  if  the  bleeding  is  still  going  on,  and  the  coagu- 
lum  not  formed  (but  unfortunately  you  will  be  very 
rarely  called  at  that  early  stage),  you  must  apply  some 
form  of  haemostatic,  ice  into  the  rectum,  etc.;  and 
speaking  of  ice  in  the  rectum,  it  may  be  applied  by  a 
gold-beater's  skin  bag  probably  better  than  in  any 
other  way;  the  bag  being  filled  with  pounded  ice,  and 
put  directly  into  the  bowel.  There  is  very  little  diffi- 
culty in  introducing  it,  if  the  anus  is  first  dilated  by 
the  finger  and  the  outside  of  the  bag  well  oiled.  As 
to  internal  means,  we  may  use  acetate  of  lead  and 
opium,  aromatic  sulphuric  acid,  or  ergot,  which  latter 
is  a  very  valuable  remedy  for  the  treatment  of  'these 
cases.  I  remember  a  case  where  gallic  acid  in  com- 
bination with  ergot  was  used  to  decided  advantage. 
The  man  recovered,  and  I  have  every  reason  to  be- 
lieve that  it  was  due  to  the  haemostatic.  Another 
antiphlogistic,  apart  from  rest,  is  a  proper  diet.  The 
bowels  must  be  kept  very  quiet  for  some  days.  You 
must  do  nothing  to  create  any  irritation  in  them.  Do 
not  give  cathartics.  Do  all  you  can  to  arrest  inflam- 
mation. You  must  wait  until  the  coagulation  is  com- 
pleted and  the  tumor  consolidated.  If  you  find  that 
after  an  apparent  consolidation  it  fluctuates,  it  is 
proper  to  open  it  freely  through  the  posterior  wall  of 
the  vagina.  By  a  free  opening  I  do  not  mean  a  large 
incision.      Take  a  narrow-bladed  knife,  or  bistoury. 


—  35  — 
•and  push  it  directly  upwards  into  the  swelling,  and 
having  done  so,  work  your  finger  in  and  enlarge  the 
■wound.  Professor  Simpson  recommended  that  the 
trocar  and  cannula  be  used,  but  he  later  retracted  that 
recommendation,  saying  that  he  frequently  found  the 
blood  too  thick  to  flow  through  the  cannula.  He 
subsequently  put  in  a  piece  of  lint  to  keep  the  wound 
■open  and  wash  out  the  cavity.  At  present  I  use  a 
-very  weak  bromine  solution,  and  the  ordinary  rubber 
■drainage  tube  to  keep  the  wound  open.  Stimulants 
are  to  be  given  the  patient,  of  course.  I  had  a  case 
in  1885,  illustrating  the  traumatic  form,  in  a  patient  in 
the  Providence  Hospital,  upon  whom  I  had  performed 
laparotomy  for  a  gun-shot  wound.  There  was  a  pel- 
vic hsematoma  pressing  on  the  rectum,  and  violent 
tenesmus  was  present.  I  passed  a  knife  through  the 
anterior  wall  of  the  rectum  and  evacuated  the  con- 
tents of  the  tumor.     The  patient  finally  recovered. 

I  have  now  to  speak  briefly  of  pudendal  hsema- 
toma.  By  hgematoma  of  the  pudendum  I  mean 
thrombus  of  the  vulva,  which  is  one  of  the  results  of 
pressure  upon  the  veins  of  the  labia  during  labor. 
Sometimes  an  enlargement  of  the  veins  and  a  swelling 
of  the  parts  begin  prior  to  labor,  and  the  veins  are 
■often  varicose.  Rupture  of  the  veins  causesthr  ombus 
and  great  pain,  which  require  surgical  interference. 
The  only  treatment  is  to  open  the  thrombus  freely" 
after  the  coagulum  is  formed,  and  if  there  is  consid- 
■erable  haemorrhage  it  should  be  arrested  by  pressure. 


-  36  - 

The  varieties  of  haematoma  are:  Cystiform,  par- 
enchymatous, and  polypoid.  One  of  the  most  typical 
forms  of  haematoma  is  scrotal  haematoma.  This,  as 
its  name  implies,  is  an  effusion  of  blood  into  the  scro- 
tum, and,  if  you  will  pardon  me  for  omitting  to  men- 
tion it  before,  I  found  in  the  College  museum  a 
specimen  of  an  ovarian  haematoma  which  shows  the 
internal  structure  very  beautifully,  and  is  well  worth 
looking  at.  It  was  removed  by  the  late  Prof.  Ash- 
ford.  If  you  will  observe,  one  of  the  ovaries  seems 
to  be  perfectly  sound,  while  the  other  has  apparently 
taken  on  a  cystiform  action.  But  let  us  return  to  the 
scrotal  haematoma.  This  is  nearly  always  caused  by 
direct  violence — a  kick  or  blow,  or  something  of  that 
kind,  in  the  groin.  I  saw  it  once  produced  where  a 
sailor  had  fallen  from  aloft  and  caught  on  the  yard- 
arm  of  the  main  mast,  striking  his  scrotum  so  that  it 
produced  this  tumor.  The  history  of  the  case  is 
almost  invariably  a  history  of  external  injury;  and 
you  will  find  that  the  swelling  comes  on  almost  imme- 
diately after  the  injury,  the  pain  not  ceasing  and  the 
swelling  remaining.  That  forms  an  element  in  the 
diagnosis  between  scrotal  haematoma,  sarcocele,  orch- 
itis, hydrocele,  and  the  various  other  diseases  of  the 
testicle  and  scrotum.  In  haematocele,  the  increase  in 
the  size  of  the  scrotum  is  sudden,  pointing  directly  to 
its  cause,  the  sudden  outflow  of  blood  producing  it. 
If  the  first  effect  has  subsided,  it  is  painless;  whereas, 
if  it  were  orchitis,  sarcocele,  or  any  other  form  of  car- 


—  37  — 

•cinoma,  there  would  be  continuing  pain.  So  that  if 
you  find  a  tumor  of  the  scrotum  which  has  grown 
suddenly  after  an  injury,  with  no  further  tendency  to 
increase,  then  you  may  suspect  that  you  have  to  deal 
with  scrotal  haematoma.  If  you  examine  the  tumor 
by  transmitted  light — that  is,  by  placing  the  patient 
•on  a  table  and  looking  directly  through  the  scrotum 
with'  a  cylindrical  speculum  or  tube — if  it  be  hydro- 
cele, it  will  be  translucent,  whereas  hsematoma  will  be 
•nearly  opaque,  the  area  of  opacity  depending  upon 
the  amount  of  coagulation  present.  Opacity  would 
be  found  in  sarcocele  also;  but  you  have  the  history 
of  the  case  to  guide  you,  sarcocele  being  of  slower 
growth  and,  like  hydrocele,  keeps  on  growing.  Now, 
in  hernia  the  diagnosis  is  made  by  an  examination  of. 
the  abdominal  rings  and  by  grasping  the  swelling  to 
•detect  an  impulse.  If  it  be  hernia,  and  the  patient 
«be  directed  to  cough,  the  abdominal  impulse  will  be 
transmitted  to  the  tumor,  and  can  be  felt  by  the  fin- 
gers. In  case  of  scrotal  haematoma,  there  is  no  trans- 
mitted impulse  on  coughing.  Then  we  have  hgema- 
■toma  of  the  cord,  in  which  the  diagnosis  is  much  more 
clear,  but  you  must  depend  on  the  history  of  the  case 
io  correct  any  errors  in  the  physical  examination. 
The  diseases  known  as  bubonocele  and  varicocele 
■may  confuse  the  student.  Bubonocele  is  caused  by 
the  projection  of  a  knuckle  of  the  intestine  which 
■does  not  pass  entirely  through  the  external  ring. 
•Of    course   that    disease    must   be    diagnosed    from 


-  38  - 
hsematocele  of  the  cord.  You  can  sometimes  get  the 
transmitted  impulse  in  bubonocele,  but  not  always. 
The  tissues  surrounding  the  canal  are  so  dense  and 
fibrous  that  the  transmitted  impulse  is  less  distinct. 
When  the  contents  of  the  bubonocele  consist  of  omen- 
tum there  is  frequently  no  impulse.  If  you  can  pusb 
the  tumor  to  its  natural  place  so  that  the  swelling  en- 
tirely disappears,  it  is  probably  bubonocele  and  not 
haematoma.  Varicocele  consists  of  a  swelling  and 
enlargement  of  the  scrotal  veins.  The  swelling  feels 
like  a  bunch  of  angleworms,  so  they  say.  I  have  never 
felt  many  angleworms,  but  that  is  the  way  it  is  said 
they  would  feel,  if  we  may  believe  the  text-books. 

In  the  treatment  of  scrotal  hsematoma  and  hgema- 
toma  of  the  cord,  you  must  evacuate  the  coagulum- 
unless  you  should  find  it  disperses  of  its  own  accord,, 
for  a  simple  extravasation  usually  disappears  spon- 
taneously—but if  you  find  in  a  few  days  that  it  doe? 
not  disappear,  you  must  evacuate  it.  One  of  the  best 
means  is  what  Professor  Frank  Hamilton  called  a 
long  incision.  When  the  scrotum  is  swollen,  an  in- 
cision three  inches  long,  for  example,  through  the- 
great  retraction  will  not  be  more  than  an  inch  long — 
so  you  need  not  be  alarmed  about  making  a  long 
incision  in  the  scrotum  when  it  is  distended,  for  it 
retracts  fully  two-thirds.  If  the  incision  has  been 
made  and  you  have  turned  out  the  clot,  you  must 
clear  out  the  wound,  and  inject  a  solution  of  bichloride 
of  mercury,  i  to  4000  parts,  or  the  compound  solutioa 
of  bromine,  and  put  in  a  drainage  tube. 


—  39  — 

There  is  another  form  of  haematoma,  or  rather 
the  same  form  in  a  different  part  of  the  pelvis.  Some 
of  the  vesical  veins  sometimes  burst  and  form  pelvic 
haematoma  of  the  recto-vesical  tissue.  That  is  always 
the  result  of  injury.  It  is  scarcely  possible  to  diag- 
nosticate this  form  except  through  the  rectum,  and 
even  that  is  quite  difficult. 

I  will  now  speak  of  the  cystiform  variety.  By 
this  we  mean  any  effusion  into  a  cyst  by  sanguineous 
exudation  from  the  cyst  wall,  so  that  when  the  con- 
tents of  the  cyst  are  evacuated  they  seem  to  con- 
sist of  blood.  Sometimes  there  seems  to  be  a  pass- 
ive exudation  of  the  blood,  without  any  visible 
rupture.  In  such  cases  you  will  find  the  cyst  walls 
quite  rough,  from  inflammatory  exudations.  It  com- 
mences as  a  sort  of  vegetative  growth.  We  find 
sanguineous  effusion  into  the  cyst,  making  cystiform 
hsematoma,  also  occurring  in  hsematoma  of  various 
organs  of  the  body,  and  throughout  the  serous  and 
synovial  sacs  generally.  The  bursae  mucosae  some- 
times exhibit  this  form.  Some  of  the  older  students 
of  this  college  will  remember  a  case  in  the  Providence 
Hospital  of  a  young  negress  with  double  "  house- 
maid's knee " — that  is,  a  bursa  over  each  patella. 
One  of  them  was  entirely  sanguineous,  and  seemed  t© 
contain  nothing  but  watery  blood.  The  case  was 
cured.  There  is  no  difficulty  in  curing  such  cases. 
The  treatment  is  the  same  as  the  treatment  of  cyst,  of 
which  I  shall  speak  hereafter. 


—  40  —  • 

The  next  form  is  the  parenchymatous.  One  of 
the  best  known  varieties,  aside  from  those  collec- 
tions of  blood  sometimes  formed  in  one  of  the  solid 
viscera,  such  as  you  find  occasionally  in  the  liver,  is 
hsematoma  of  the  heart.  It  is  better  known  than  any 
other  because  the  heart  is  most  carefully  looked  after 
in  case  of  death  when  a  post-mortem  follows.  So  that 
this  disease,  haematoma  of  the  valves  of  the  heart,  has 
been  brought  into  considerable  prominence.  These 
little  tumors  are  situated  chiefly  in  the  edges  of  the 
valves,  sometimes  extending  along  their  entire  cir- 
cumference. Then  we  have,  clinically,  valvular  mur- 
mur, and  all  the  symptoms  due  to  valvular  disease  of 
the  heart.  Of  course  no  treatment  is  of  any  avail  in 
such  a  case. 

The  polypoid  is  also  quite  a  rare  form  of  hsema- 
toma.  The  most  common  form  is  that  which  origin- 
ates very  rarely  after  the  removal  of  the  placenta. 
The  tumor  more  frequently  occurs  in  abortion  than  in 
natural  labor.  It  varies  in  size  from  a  filbert  to  a 
walnut.  It  seems  to  be  formed  where  a  portion  of 
the  placenta  has  grown  to  the  uterine  wall.  Just  there 
a  clot  is  formed,  which  is  pushed  out  and  projects 
into  the  uterine  cavity,  in  some  cases  almost  entirely 
filling  it.  It  is  termed  polypoid  because  it  is  like  a 
polypus  in  appearance,  but  it  is  only  apparent,  as  you 
shall  presently  see. 

I  will  now  proceed  to  class  2:— Transudation  and 
exudation  tumors.     The  chief  variety  is  hygroma,  or 


—  41    — 

watery  tumor,  or  serous  cyst,  as  it  is  sometimes  called. 
We  have  dropsy  of  the  bursse  mucosae,  proliferating 
hygroma  of  bursse,  and  ganglion. 

First  is  the  hygroma,  which  is  the  common  watery 
tumor  sometimes  called  a  barren  cyst,  or  watery  cyst. 
Sometimes  they  are  called  cysts  of  dilatation,  in  order 
to  distinguish  them  from  the  cyst  proper,  which  is 
due  to  retention.  Now  let  us  clearly  understand 
what  is  meant  by  dilatation  and  retention.  When  a 
cyst  is  formed  by  the  damming  up  of  a  duct,  that  is 
a  cyst  from  retention.  A  cyst  from  dilatation  means 
a  cyst  formed  by  dilatation  from  an  inflammatory 
process  of  the  sac  wall  and  an  actual  increase  in  the 
natural  fluid  produced,  so  that  it  does  not  appropri- 
ately come  under  the  term  "  cyst,"  though  ordinarily 
speaking  we  would  call  it  such.  Hygroma  proper  is, 
therefore,  different  from  a  diseased  bursa.  Those 
cysts  that  are  found  along  the  fascia  lata  are  of  this 
variety. 

A  proliferating  hygroma  is  an  abnormal  struc- 
ture from  the  beginning.  The  contents  of  the.  bursa 
are  constantly  augmenting.  They  push  aside  the 
covering  tissue,  and  form  new  fibrous  coverings. 
They  are  sometimes  traversed  by  bands  of  connective 
tissue,  which  subdivide  them,  and  they  are  then 
called  multilocular.  Housemaid's  knee  is  one  of 
the  most  common  varieties.  The  origin  of  house- 
maid's knee  is  very  doubtful.  If  this  old  skeleton, 
hanging  in  our  lecture  room,  were    a    recent    subject 


—  42   — 

instead  of  a  dried-up  old  veteran,  we  would  see  that 
the  weight  of  that  knee  rested  upon  the  condyles 
of  the  femur  and  the  head  of  the  tibia,  and  not  upon 
the  patella.  The  patella  is  entirely  out  of  harm's 
way.  So  that  it  is  very  doubtful  if  housemaid's  knee 
is  caused  by  working  in  that  position.  But  the  irrita- 
tion of  the  quadriceps  tendon  may  produce  it.  If 
kneeling  were  the  constant  cause,  carpet-layers  would 
have  it;  but  they  are  not  predisposed  to  housemaid's 
knee.  The  diagnosis  is  easily  established.  Upon 
pressing  the  patella  from  side  to  side,  the  tumor 
moves  with  it.  In  enlargement  of  the  joint  you  must 
remember  that  the  synovial  sac  extends  two  or  three 
inches  above  the  patella;  so  that  if  you  were  to  press 
it  at  the  side  and  above  the  patella  you 'would  find 
fluctuation.  In  housemaid's  knee  you  cannot  do  that. 
There  is  no  distinct  fluctuation  behind  the  patella 
from  side  to  side  above  the  upper  border.  All  fluc- 
tuation that  you  can  obtain  is  from  before  backwards. 
Then  the  configuration  of  the  tumor  in  case  of  house- 
maid's knee  is  conical.  It  projects  directly  in  front 
of  the  patella. 

The  treatment  of  this  affection  may  be  external, 
or  you  may  be  able  to  produce  absorption  by  the  in- 
ternal use  of  iodide  of  potassium  and  the  external 
application  of  iodine.  It  is  well  to  try  that  in  the  be- 
ginning, but  usually  you  must  not  expect  to  cure  your 
patients  by  these  means.  You  may  finally  cure  them, 
for  in  the  majority  of  cases  the  treatment  will  be  that 


—  43  — 
of  making  an  incision  into  the  tumor  and  evacuating 
its  contents,  or  by  a  trocar  and  cannula  and  the  injec- 
tion of  tincture  of  iodine.  Very  frequently  you  will 
find  the  contents  consist  of  thick  fluid.  In  that  case 
the  use  of  the  trocar  will  be  impracticable,  but  a  free 
incision  might  be  made  directly  into  the  swelling,  or 
you  might  inject  iodine,  passing  it  freely  around  into 
the  structure.  If  the  sac  is  multilocular,  great  care 
will  have  to  be  taken  to  reach  all  parts  of  the  struc- 
ture. It  must  be  almost  completely  extirpated,  or  the 
disease  will  recur. 

Dropsy  of  the  bursce.  mucosce  is  an  increase  in 
the  natural  fluids  of  the  part.  They  are  usually 
chronic  and  pendulous.  They  do  not  give  the  pa- 
tient any  uneasiness  or  pain,  but  they  are  in  the 
way.  Proliferating  hygroma  of  bursse  mucosae  may 
sometimes  co-exist  with  sarcomatous  growths,  and  it 
is  very  doubtful  whether  they  do  not  belong  more 
properly  to  proliferation  tumors.  When  co-existent 
with  a  sarcomatous  growth,  they  partake  of  its  nature. 
The  treatment  of  uncomplicated  dropsy  of  bursa  is 
by  free  incision;  and  if  there  is  great  haemorrhage 
from  the  tumor,  it  should  be  treated  with  the  thermo- 
cautery. • 

Last  is  the  so-called  ganglion,  which  is  a  simple 
abnormal  swelling  caused  by  an  exudation  or  increase 
in  the  synovial  fluid.  The  word  ganglion  is  a  mis- 
nomer as  applied  to  these  tumors.  The  term  has  not 
the  slightest  significance  as  to  the  nature  of  the  tumors 


—  44  — 

—but  they  are  called  ganglions.  I  think  I  can  give 
you  a  little  diagram  here  which  will  show  you  the 
nature  of  this  ganglion.     We  will  say  that  this  broad 


line  is  a  tendon,  the  sheath  of  the  tendon  lying  just 
above  it.  Now  you  will  observe  that  this  sheath  has 
been  pushed  up.  It  is  simply  a  protrusion  above  the 
tendon.  The  sheath  is  not  ruptured;  it  simply  pro- 
trudes, and  raises  the  skin.  The  contents  of  this 
ganglion  do  not  differ  from  the  natural  contents  of 
the  §heath,  except  in  amount.  They  most  commonly 
appear  on  the  tendons  on  the  dorsum  of  the  hand, 
but  I  have  had  under  treatment  a  case  where  the 
ganglion  was  situated  underneath  the  flexor  tendon 
of  the  index  finger,  under  the  palmar  fascia.  The 
treatment  is  almost  the  same  as  in  the  other  varieties 
of  hygroma.  You  may  lay  them  open,  but  the  quick- 
est and  easiest  way  is  to  take  a  book  and  break  them 
by  a  sharp  blow.  The  forcible  rupture  of  the  ganglion 
will  cause  it  to  disappear;  placing  a  bandage  on  it 
with  moderate  pressure  will  be  sufficient.  I  saw  one 
at  Providence  Hospital  I  was  unable  to  rupture  by 
th£  hardest  stroke.  It  seemed  to  be  multilocular. 
Failing  to  rupture  it  in  the  usual  way,  I  made  an  in- 
cision entirely  through  the  tumor  down  to  the  tendon, 
and  laid  in  a  pledget  of  lint  saturated  with  bichloride 
of  mercury  solution,  after  having  first  injected  tinc- 
ture  of  iodine,  pressing  it  about  so  that  the  iodine 


—  45  — 
penetrated  every  portion  of  the  tumor  sac.  The  man 
made  a  good  recovery.  We  call  the  thick  fluid  "  meli- 
ceris,"  or  honey  wax.  When  the  ganglion  occurs  in 
the  palm  you  will  be  unable  to  rupture  it  by  a  blow; 
incision  and  injection  will  be  required. 


LECTURE  IV. 

RETENTION  TUMORS. 

At  the  last  lecture  we  considered  the  first  of  the 
two  classes  of  tumors —extravasation  tumors,  and 
transudation  and  exudation  tumors;  but  I  did  not 
quite  finish  the  discussion  of  that  class.  I  should 
have  said  that  transudation,  exudation,  and  retention 
tumors  are  of  the  cystic  variety,  as  you  may  notice  by 
looking  at  your  classification  table.  Now,  what  do 
we  mean  by  "cystic"  ?  We  mean  a  sack  or  bag  con- 
taining fluid.  In  the  case  of  retention  tumors,  it  is 
simply  an  extension  or  distension  of  the  normal  mem- 
brane; in  transudation  and  exudation  tumors,  the 
membrane  is  formed  de  novo  from  the  inflammatory 
action,  as  well  as  by  the  proliferation  of  the  edges  of 
the  original  sac. 

According  to  the  Virchownian  classification,  the 
retention  tumor  is  simply  a  damming  up  of  a  duct 
from  some  gland,  or  the  retention  in  the  gland  itself 
of  matter  which  is  there  secreted  and  usually  thrown 
out.  In  that  case  we  have  a  dilatation  of  the  natural 
sac,  and  a  cyst  is  formed. 

Cysts  may  be  formed  in  almost  every  portion  of 
the  body,  except  perhaps  in  the  substance  of  the 
lymphatic  glands.  It  is  quite  probable  that  this  de- 
generation may  take  place  in  all  parts  of  the  body, 
but  it  is  a  fact  that  the  lymphatic  glands  are  notably 


—  47  — 
free  from  cystic  degeneration.  Billroth  says  that 
closed  follicles  of  the  lymphatic  glands  never  give 
rise  to  cysts,  but  "any  tissue  rich  in  cells  may  be 
transformed  into  a  cyst  by  metamorphosis  of  proto- 
plasm, or,  as  others  express  it,  by  separation  of  the 
mucous  substance,  through  cells,  without  connection 
with  development  of  the  mucous  glands."  Bone 
cysts,  as  you  may  readily  imagine,  not  having  any 
■  normal  membranous  structure,  must  always  originate 
by  softening,  and  are,  therefore,  practically  exudation 
tumors.  Of  the  bony  cysts  to  which  I  will  direct 
your  attention,  perhaps  the  most  important  are  those 
of  the  upper  and  lower  jaw.  These  cysts  are  usually 
in  the  beginning  multilocular — that  is  to  say,  divided 
into  compartments  — but  finally  become  monolocular. 
Sometimes  we  find  them  in  the  upper  jaw,  constituting 
a  cystic  degeneration  of  the  antrum  Highmorianum. 

In  this  cavity  the  mucous  lining  first  becomes 
irritated  at  some  point,  where  a  papilla  appears 
and  a  cystic  degeneration  takes  place.'  Sometimes 
these  cysts  entirely  stud  the  inside  lining  mem- 
brane of  the  canal.  In  other  instances  they  coalesce 
and  fill  up  the  antrum,  and  after  a  while  push  out  its 
walls  so  that  the  face  is  much  deformed,  and  the  jaw 
becomes  diseased.  Sometimes  these  cystic  tumors  of 
the  upper  jaw  spring  from  the  alveolar  projection  of 
the  socket  of  the  teeth,  where  the  fang  projects  into 
the  antrum.  If  ydu  examined  the  inside  of  the  upper 
jaw,  you  would  see  that  the  fangs  of  the  teeth  pro- 


-  48  - 

jected  deeply  into  it,  covered  by  the  bony  alveolar 
process.  Sometimes  a  cystic  degeneration  takes 
place  from  the  alveolar  process  on  the  outside.  First 
there  is  a  damming  up  of  a  mucous  duct,  which 
causes  distension,  and  a  cystic  tumor  is  formed.  We 
find  it  occasionally  in  the  case  of  delayed  or  displaced 
teeth,  and  sometimes  in  the  case  of  children,  where 
the  temporary  teeth  have  been  delayed  far  beyond 
the  normal  period.  Occasionally  the  permanent  teeth  • 
are  delayed,  and  a  cyst  forms,  which  contains  teeth. 
These  are  called  dentigerous  cysts. 

The  size  of  a  tumor  of  the  antrum  may  vary  from 
the  size  of  a  pea  upwards.  Sometimes  they  will  be  pro- 
liferating and  hard,  and  you  will  scarcely  know  them  to 
be  cysts  except  by  examination  after  removal.  At  other 
times  the  face  is  greatly  distorted  and  deformed.  The 
contents  of  these  cysts  will  be  found  the  usual  color 
and  consistency  of  cystic  tumors  elsewhere  in  the  body. 
There  is  generally  a  pea-green,  albuminous  fluid,  thin- 
ner than  the  white  of  an  egg,  which  upon  examination 
is  sometimes  found  to  be  highly  albuminous.  Some- 
times the  contents  of  these  tumors  calcify;  chalk  con- 
cretions are  formed  and  disappear;  occasionally,  by 
reason  of  the  rapid  growth  of  the  cyst  and  the  press- 
ure of  contiguous  parts,  it  creates  inflammation,  when, 
by  means  of  the  suppurating  process,  we  have  a  spon- 
taneous cure.  All  these  cystic  tumors,  especially  the 
benign  class,  are  of  very  slow  growth,  and  that  is  one 
point  in   the  diagnosis.     Where  these  cystic  tumors 


—  49  — 
form  in  the  upper  jaw,  a  bulging  will  take  place  which 
not  infrequently  forces  the  hard  palate  down  into  the 
mouth.  You  can  sometimes  see  that  the  hard  palate 
is  pushed  down  almost  to  a  level  with  the  teeth,  and 
by  the  finger  you  can  push  into  the  tumor  or  feel  it 
fluctuate.  These  tumors  are  not  painful  as  a  general 
thing. 

Diagnosis:  If  you  take  into  account  their  pain- 
lessness, their  slow  growth,  the  absence  of  any  consti- 
tutional taint,  the  character  of  the  fluid  on  examina- 
tion, you  may  give  a  pretty  positive  diagnosis  as  t© 
the  character  of  the  tumor. 

Treatment:  There  are  several  methods  of  treaty 
ment.  You  may  open  the  cyst  and  evacuate  the  con- 
tents, trusting  to  nature  for  a  sufficient  amount  of 
inflammation  to  be  caused  to  complete  the  cure.  Or 
you  may  push  a  trocar  into  the  tumor  and  evacuate 
its  contents,  and  then  inject  .it  with  iodine.  That  is 
perhaps  the  best  method;  but  you  must  take  care 
that  every  part  of  the  diseased  membrane  is  reached 
by  the  iodine.  When  these  tumors  are  very  large  you 
will  usually  find  that  the  simple  tapping  and  injection 
of  iodine  will  not  perfectly  cure  them;  so  that  you 
must  thoroughly  extirpate  them  with  the  knife  and 
bone-gnawing  forceps,  or  the  curette,  arresting  any 
hsemorrhage  during  the  process  by  means  of  Pacque- 
lin's  thermo-cautery,  or  the  electric  cautery. 

Cystic  tumors  of  the  lower  jaw  usually  appear 
near  the  upper   border  of  the  bone.     They  usually 


—  5°  — 
originate  in  the  cancellous  structure  of  the  bone— that 
is,  between  the  two  plates — so  that  in  case  of  cystic 
disease  of  that  bone  it  separates  the  plates.  It  is  not 
true,  however,  that  the  two  plates  diverge  equally; 
the  inner  plate  being  thinner,  the  tumor  encroaches 
on  the  mouth.  A  cystic  tumor  of  the  lower  jaw  is 
usually  quite  painful,  owing  to  the  pressure  upon  the 
inferior  dental  nerve  at  that  point,  and,  perhaps,  to  the 
stretching  of  the  nerve.  I  have  spoken  of  the  malig- 
nant form  of  cystic  tumor,  and  should  tell  you,  before 
going  into  the  subject  of  proliferation  tumors  proper, 
that  cystic  tumors  of  the  lower  jaw  are  very  apt  to 
take  on  malignant  forms— that  is  to  say,  cancer  cells 
may  be  developed  therein.  Multilocular  cystoma  of 
the  lower  jaw  is  frequently  cancerous,  so  it  is  very  im- 
portant to  make  an  accurate  diagnosis,  which  can 
only  be  done  by  the  aid  of  the  microscope.  You  also 
find  that  in  these  tumors  the  ordinary  cystic,  and  I 
might  say  the  sarcomatous  tumor  as  well,  does  not 
recur  after  extirpation,  except  in  cases  of  round-celled 
sarcomata,  which  are  malignant. 

It  is  only  necessary  to  thrust  thp  trocar  into  the 
cavity  of  the  tumor,  evacuate  the  contents,  and  inject 
tincture  of  iodine.  Some  surgeons  press  the  bony 
walls  together  with  the  thumb  and  finger,  in  order  to 
crush  the  outer  plate;  this  is  not  always  practicable, 
although  the  plate  is  thin.  When  a  sarcomatous 
tumor  has  involved  the  bone  so  as  to  cause  its  en- 
largement, you  will  find  it  necessary  to  remove  the 


—  51  — 
entire  bone,  by  making  an  incision,  separating  the 
bone  at  the  symphisis,  with  a  chain-saw,  and  dis- 
articulating the  lower  jaw.  When  the  periosteum  can 
be  saved,  it  is  very  desirable  to  do  so,  because  a  bony 
'Structure  may  be  formed  which  will  aid  in  preserving 
the  normal  contour,  and  prevent  deformity.  If  not, 
you  have  done  no  better  nor  worse  than  the  majority 
of  cases;  but  you  have  at  least  had  the  satisfaction  of 
curing  your  patients,  for  they  almost  invariably  get 
well  after  the  operation. 

The  soft  parts  also  take  on  cystic  degeneration, 
not  only  in  the  softer  mucous  tissues,  but  the  myoma- 
tous growths  and  the  various  viscera  of  the  body. 
Speaking  of  myomatous  growths,  you  know  what 
myomata  are  ?  They  are  tumors  composed  of  muscu- 
lar structure,  and  are  very  frequent  in  the  uterus.  By 
means  of  what  is  known  as  cystic  degeneration,  they 
sometimes  soften  and  become  cysts.  The  glands — 
the  thyreoid,  for  instance — often  become  the  seat  of  ^ 
cystic  tumors,  which  originate  in  the  alveolae  of  the 
gland,  and  gradually  distend  it.  Sometimes  a  haemor- 
rhage occurs  into  the  sac,  and  then  they  are  called 
haemorrhagic  cysts. 

Cystic  Bronchocele.  This  always  originates  as  a 
minute  cyst.  It  may  be  as  small  as  a  pin-head 
in  the  beginning,  but  greatly  enlarges,  and  finally  be- 
comes an  immense  cystic  growth.  When  the  cysts  of 
the  thyreoid  gland  are  very  large,  they  are  called  thy- 
reoid goitre.     They  extend  sometimes  entirely  across 


—  52  — 
the  front  of  the  neck,  swelHng  it  and  raising  the  chin. 
Hemorrhagic  bronchocele  is  comparatively  easy  tO' 
diagnose  from  goitre,  because  goitre  proper  is  simply 
a  hypertrophy  of  the  thyreoid  gland — fibrous  goitre. 
There  is  no  fluctuation  in  goitre.  In  a  cyst  there  is- 
fluctuation,  because  it  is  fluid.  As  to  the  history  of 
the  case,  it  is  proper  to  say  that  cystic  disease  of  the 
thyreoid  occurs  about  as  often  as  goitre  in  those  locali- 
ties where  goitre  is  prevalent,  in  some  of  the  valleys 
of  the  Alps.  Professor  Frank  Hamilton,  in  speaking 
of  goitre,  said  he  had  occasion  to  go  over  to  Switzer- 
land, and  wanted  to  see  why  goitre  was  more  prevalent 
in  the  Alps  than  in  other  localities  of  Europe.  He 
found  it  most  prevalent  in  those  deep  valleys  where- 
the  sun  never  shone,  where  it  was  continuously  damp^ 
where  twilight  came  early, 'and  daylight  late.  The  in- 
habitants were  languid  and  insufficiently  fed;  so  that 
not  only  the  climate,  but  inadequate  food,  aided  in  its 
production.  But  this  is  a  by-path.  Let  us  return  to 
the  cystic  tumor  of  the  thyreoid.  Like  its  predeces- 
sors, its  growth  is  very  slow.  It  is  annoying  to  the 
patient,  not  from  pain,  but  fram  pressure.  Sometimes, 
it  presses  on  the  trachea,  and  then  there  is  difficulty 
i  n  breathing  and  in  swallowing.  Whenever  you  are 
in  doubt  as  to  the  precise  character  of  the  tumor,  use 
the  exploring  needle.  One  of  the  oldest  forms  of 
treatment  is  by  the  seton,  originated  in  the  time  of 
Celsus;  but  it  is  not  without  danger,  principally  from^ 
haemorrhage  and  septicaemia.     In  fact,  modern  anti- 


—  53  — 
:septic  surgery  practically  excludes  the  seton  as  a 
therapeutic  measure.  Occasionally  a  blood-vessel  or 
vein  is  involved,  and  the  vein  becomes  ulcerated;  then 
we  may  have  phlebitis,  and  pyaemia  follows.  Tapping 
is  another  method  of  treatment,  but  not  altogether 
safe,  a  case  having  been  reported  in  which  rupture 
into  the  larynx  and  pharynx  followed.  Tapping,  fol- 
lowed by  the  injection  of  iodine,  has  been  more  satis- 
factory, and  injection  of  carbolic  acid  was  practiced 
by  the  late  Professor  Gunn,  of  Chicago,  in  cases  of 
cystic  goitre,  with  considerable  success. 

Incision  into  these  tumors  has  been  practiced 
very  frequently,  but  that,  like  all  other  methods,  is 
-dangerous,  the  gland  being  always  vascular.  A  punc- 
ture in  any  part  is  followed  by  haemorrhage,  and  an 
incision  by  very  great  haemorrhage.  The  larger  the 
cyst,  the  more  formidable  it  is  for  treatment  by  in- 
cision. If  it  be  treated  by  incision,-  it  should  be 
tightly  packed  with  lint,  having  been  previously  washed 
out  with  the  mercuric  bichloride  solution,  or  tincture 
•of  iodine  injected.  Beck,  of  Freiberg,  prefers  a  much 
more  radical  treatment.  Freiberg  is  a  place  where 
more  of  these  growths  are  reported  than  in  any  other 
place  in  the  world.  Beck  treated  thirteen  cases  by 
complete  extirpation.  Two  of  the  cases  recovered 
after  a  long  and  tedious  suppuration;  eleven  died. 
The  dangers  of  the  operation  do  not  cease  with  the 
closure  of  the  wound,  for  it  has  been  found  that  after 
the  removal  of  the  gland  myxoedema  was  apt  to  fol- 


—  54  — 
low,  and  Horsley  has  shown  that  there  is  a  great  con- 
nection between  the  mental  disease  and  the  loss  of 
the  gland.  But  in  cystic  disease  the  gland  must 
necessarily  have  been  previously  destroyed  by  the  pro- 
gress of  the  disease,  so  that  while  the  observation  of 
Horsley  may  hold  good  in  true  goitre,  it  has  much> 
less  weight  in  the  cystic  goitre.  Many  other  opera- 
tors have  followed  this  plan.  Electrolysis  has  been' 
proposed  as  one  of  the  best  means  of  treatment  in 
these  cases;  but  we  must  learn  a  great  deal  more 
about  electricity  before  we  can  treat  these  tumors- 
with  it  successfully.  The  method  of  treatment  by  the 
electric  pole  is  simply  by  dissolving  the  tissue.  All 
that  you  see  is  a  little  greenish  fluid  about  the  pole, 
and  a  bubbling  up  of  gases.  In  other  words,  the  tis- 
sue in  contact  with  the  electrode  is  dissolved  into  its. 
original  elements.  It  is  as  near  total  annihilation  of 
that  tissue  as  you  can  well  imagine.  While  I  would 
recommend  you  to  use  the  thermo-cautery  in  cases- 
where  the  whole  gland  is  involved,  I  prefer  extirpa- 
tion when  they  are  unilateral.  It  might  be  well  to- 
note  in  passing  the  occasional  success  of  the  treat- 
ment of  solid  bronchoceles  by  the  internal  use  of 
iodide  of  potassium  and  the  external  use  of  iodide  of 
lead.  The  operation  of  removing  one-half  the  gland., 
having  at  its  commencement  tied  the  isthmus,  is  quite 
satisfactory  in  the  young.  It  is  said  that  myxoedema 
does  not  follow  in  any  case  where  a  portion  of  the 
gland  is  allowed  to  remain,  and  I  have  seen  no  case 


—  55  — 
of  partial  extirpation  where  any  serious  results  fol- 
lowed this  operation. 

Retention  Tumors.  There  are  several  varieties  of 
these  to  which  I  shall  hereafter  invite  your  attention: 

a.  Ranula. 

b.  Parovarian. 

c.  Wen. 

d.  Mucocele. 

The  above  class  belongs  to  the  true  cysts.  We 
will  take  up  retention  tumors  in  the  various  structures 
of  the  body.  First,  in  the  skin:  The  retention  cysts 
of  the  skin  are  mostly  found  about  the  face  and  nose, 
in  the  ducts  of  the  sebaceous  glands.  They  are  little 
black  specks  on  the  face,  are  called  comedones, 
and  are  due  to  the  damming  up  of  the  sebaceous 
ducts,  and  the  lodgment  of  dirt,  giving  the  appear- 
ance, upon  being  squeezed  out,  of  a  maggot  with  a 
black  head.  This  is  a  true  cyst.  The  trachea,  almost 
the  last  place  where  we  would  expect  to  find  a  cyst,  is 
frequently  the  seat  of  cystic  tumors.  The  mucous 
glands  throw  out  the  secretion  which,  by  retention 
from  damming  of  the  ducts,  forms  the  cystic  tumor  of 
the  trachea.  The  stomach  is  also  occasionally  the  seat 
of  cystic  tumors;  the  result  is  hypertrophy  of  the  mu- 
cous membrane,  a  gastritis  called  gastritis  mucosum 
occurs,  and,  as  a  result,  polypoid  growths  follow.  At 
the  base  of  these  polypoid  growths  we  have  the  dilated 
mucous  ducts,  which  dilations  become  cysts,  which  can- 
not be  distinguished  during  life.     In  the  liver  we  some- 


times  find  similar  cysts,  supposed  to  be  distensions, 
being  composed  of  minute  bile  ducts,  containing  bile, 
cholesterin,  and  other  salts.  The  pancreas  has  a  cyst 
of  the  ducts.  They  become  filled  with  a  secretion 
— the  so-called  acne  pancf'eaticus,  sometimes  called 
pancreatic  ranula.  Once  in  a  while  these  pancreatic 
ducts  become  filled  with  a  chalky  concretion,  and  in 
that  case  an  inflammatory  process  results.  The  intes- 
tines are  occasionally  the.  seat  of  cystic  tumors,  pro- 
duced by  the  swelling  of  the  ducts  of  the  intestinal 
follicles.  In  speaking  of  intestinal  cysts  I  have  not 
mentioned  cyst  of  the  gall-bladder,  due  to  the  forma- 
tion of  a  large  gall-stone;  nor  of  that  due  to  obstruc- 
tion in  the  appendix  vermiformis.  We  have  a  variety 
of  small  pin-headed  cysts  in  the  kidney;  also  in  the 
tubules  from  interstitial  nephritis.  These  are  very 
small,  and  can  be  seen  only  with  the  microscope. 
Finally,  in  the  kidney  we  may  have  cysts  of  the  most 
variable  size.  We  have  that  peculiar  cyst  found  in 
the  new-born  child,  hydrops  neonatorum.  In  that 
case  it  is  enormously  enlarged.  Cysts  of  the  kidney 
usually  follow  chronic  inflammation  of  the  otgan — 
very  rarely  the  acute  form.  Now,  the  cysts  of  the 
kidney  sometimes  grow  very  large,  and  inflammation 
is  set  up;  and  if  the  patient  lives  long  enough  for 
suppuration  to  develop,  or  for  the  cyst  to  acquire  con- 
siderable size,  the  case  may  fall  into  the  hands  of  the 
surgeon.  Simple  cysts  of  the  uterus  are  formed  from 
the    retained  matter  of   the    utricular    glands.     The 


—  57  —      ■ 
mouths  of  the  ducts  of  these  glands  become  entirely 
closed,  and  the  secretion  is  retained.     Sometimes  the 
entire  surface  becomes  so  generally  obstructed  that 
we  have  the  acne  formation,  like  that  of  the  pancreas. 


LECTURE  V. 

RETENTION  TUMORS,  CONTINUED. 

At  the  last  lecture  I  spoke  to  you  hastily  on  the 
cysts  of  the  organs  in  general,  the  internal  viscera  of 
the  body,  and  referred  to  that  other  variety  of  cysts 
due  to  the  occlusion  of  the  larger  canals,  such  as 
the  bile  duct,  and  those  cysts  of  the  liver  due  to 
the  occlusion  of  the  smaller  tributaries  of  the  main 
duct,  and  also  of  the  ureter,  or  kidney.  There  are 
still  other  varieties  of  cysts  which  I  mentioned, 
such  as  those  small  cysts  due  to  closure  of  the 
ducts,  with  dilatation  of  the  bronchial  and  tracheal 
mucous  glands.  Dropsical  or  sacculated  bronchiec- 
tases and  trachiectases  are  simple  mucous  cysts,  due 
to  the  occlusion  of  the  mucous  glands  situated  in  the 
trachea  and  bronchi.  They  cut  a  very  important 
figure  in  diseases  of  the  air  passages,  but  are  of  little 
practical  interest  to  the  surgeon. 

We  will  now  take  up  the  subject  of  ovarian  cysts. 
I  may  say  at  the  commencement  that  I  do  not  intend 
to  discuss  it  from  the  standpoint  of  the  gynaecologist, 
or  go  deeply  into  that  field,  because  the  gynaecologists 
have  almost  captured  that  branch  of  surgery.  It  is 
yearly  growing  less  common  in  the  larger  cities  for 
the  general  surgeon  to  be  called  upon  to  perform 
ovariotomy. 


—  59  — 
I  have  a  couple  of  specimens  here  which  I  wish 
to  show  you,  that  were  removed  by  the  late  Professor 
Elliott,  and  beautifully  exhibit  the  structure  of  the 
ovarian  cyst,  which,  as  a  general  thing,  originates  in 
the  Graafian  follicles.  It  is  composed  of  a  very 
tough,  dense,  fibrous  structure,  due  to  the  dilatation 
and  growth  of  the  cyst  wall — the  proper  tunic  or  sac 
of  the  ovary.  Now  this  tumor  differs  from  ovarian 
dropsy  very  materially,  because  the  latter  was  origin- 
ally an  inflammation  of  the  membrane.  This,  on  the 
contrary,  is  a  cystic  degeneration  of  the  follicle,  while 
the  dropsy  originates  in  the  membrane,  and  the  fluid 
is  the  serous  exudate.  Ovarian  cysts  generally  origi- 
nate before  puberty.  Virchow  relates  the  case  of  a 
child  ten  years  of  age  in  which  the  cyst  was  fully 
formed.  I  once  assisted  Professor  J.  Taber  Johnson 
in  performing  Battey's  operation  for  hygroma  of  the 
ovary,  and  in  its  removal  we  found  not  only  hygroma, 
but  several  young  cysts  of  the  size  of  hazel  nuts, 
which  in  the  course  of  time  would  doubtless  have 
developed  into  fully  formed  ovarian  tumors.  I  will 
leave  the  pathology  of  the  ovarian  cyst  to  the  Pro- 
fessor of  Gynsecology,  and  go  on  to  the  diagnosis. 
In  the  first  place,  a  faecal  accumulation  may  be  mis- 
taken for  an  ovarian  tumor.  In  fashionable  society 
it  is  not  very  uncommon  for  young  ladies  to  allow 
great  accumulations  in  their  rectums.  It  is  incon- 
venient to  go  to  the  closet;  they  become  perfectly 
unconcerned  as  to  results,  and  finally  there  is  a  dis- 


—  6o  — 

inclination  to  go  to  stool  more  than  two  or  three  times 
a  week.  This  results  in  the  development  of  an 
enormous  amount  of  gas  and  a  swelling  of  the  abdo- 
men. The  means  of  making  the  diagnosis  between 
ovarian  tumor  and  faecal  accumulations  will  be, 
knowledge  of  the  history  of  the  case;  examination  by 
passing  the  finger  along  the  wall  of  the  vagina  and 
conjoined  manipulation  of  the  abdomen  will  de- 
tect the  swelling  in  the  bowel  caused  by  the  faecal 
accumulation.  A  more  common  -affection,  known 
as  pregnancy,  has  been  mistaken  for  tumor.  Of 
course,  you  will  understand  that  the  general  signs  of 
pregnancy  will  be  almost  entirely  absent  in  such  cases. 
Fibro-muscular  tumors  of  the  uterus  are  very  fre- 
quently mistaken  for  ovarian  tumors.  If  you  intro- 
duce a  sound  into  the  uterus  where  there  is  an  extra- 
mural muscular  tumor,  it  will  not  pass  so  far  as  in  the 
impregnated  state;  in  the  former  three  or  four  inches, 
whereas  in  the  pregnant  uterus  it  may  pass  in  eight 
to  twelve  inches.  In  uterine  tumors,  except  fibroids, 
there  is  but  little  change  in  the  menstrual  flow.  In 
ovarian  tumors  the  flow  usually  ceases — not  always, 
however,  for,  if  one  ovary  remains  healthy,  the  menses 
are  affected  in  a  less  degree.  Ordinary  dropsy  is 
sometimes  difficult  to  diagnose  from  large  ovarian 
tumor.  If  the  patient  be  placed  on  the  back  in 
ordinary  dropsy  there  will  be  a  general  flattening  of 
the  tumor,  owing  to  the  fluid  passing  into  all  parts  of 
the  cavity;    whereas,  in  ovarian   tumor  there  is  less 


—  6i   — 

flattening,  because  the  tumor  is  firmly  held  by  its  sac, 
and  does  not  flatten  by  the  simple  weight  of  its  own 
contents,  as  a  dropsical  accumulation  would.  Then 
the  history  of  the  case  gives  pretty  conclusive 
evidence  of  its  nature.  You  will  remember  in  the 
one  case  there  had  been  pain  in  one  or  other  of  the 
iliac  fossae.  The  growth  was  slow  and  the  health  not 
generally  affected,  while  in  ascites  there  is  little  pain, 
and  almost  always  impairment  of  the  health.  The 
ovarian  cells,  so-called,  have  not  been  found  so  con- 
stant as  the  discoverers  claimed  they  would  be  in  the 
beginning,  so  that  the  microscopical  examination  is 
not  looked  upon  as  a  positive  diagnosis.  Absence  of 
albumen  is  said  to  be  another  diagnostic  point,  but 
this  also  is  fallacious,  because  you  will  find  that  the 
ascitic  fluid  is,  in  a  greater  or  less  degree,  albumin- 
ous. Hydatid  tumors  of  the  uterus — cystic  tumors 
due  to  parasites,  the  echinococcus,  etc.;  these  are  also 
to  be  differentiated.  It  is  very  difficult  to  make  a 
diagnosis  between  hydatid  and  ovarian  tumor.  It  is 
found,  however,  on  investigation  of  the  history  of  the 
case,  that  when  it  originated  there  were  some  uterine 
disorders,  with  pain  referred  almost  entirely  to  the 
uterus,  and  swelling  referred  almost  entirely  to  the 
median  line.  I  might  mention  that  upon  microscopic 
investigation  of  the  fluid,  which  can  be  obtained  by 
means  of  an  aspirator  or  hypodermatic  syringe,  you 
may  see  the  parasite  under  the  microscope.  Hsema- 
tometra,  which  is  an  accumulation  of  menstrual  blood 


—    62     — 

from  an  imperforate  hymen  or  from  closure  of  the 
cervix,  might  possibly  be  confused  with  uterine  hyda- 
tids in  diagnosis.  There  is  still  another  disorder 
liable  to  be  mistaken  for  uterine  or  ovarian  tumor — 
spurious  or  phantom  pregnancy.  This  will  frequently 
occur  in  married  ladies  past  30  years  of  age,  and  more 
frequently  in  those  who  have  a  great  desire  to  have 
children.  There  will  be  observed  the  same  swelling 
of  the  abdomen,  frequently  quite  tense.  It  may  be 
diagnosticated  from  tumor  by  giving  an  anaesthetic, 
when  the  tumor  will  disappear  in  spurious  pregnancy, 
and  the  abdomen  immediately  flatten.  The  percus- 
sion note  is  quite  different  in  a  fluid  from  a  solid  tu- 
mor, and  by  percussion  its  outlines  may  be  mapped 
out.  Then,  if  the  wall  of  the  cyst  be  not  very  tense, 
you  can  get  fluctuation.  Sometimes  in  multilocular 
tumors,  and  those  with  thick  walls,  there  will  be  very 
little  fluctuation,  if  any.  Both  of  the  patients  from 
whom  these  tumors  were  removed  recovered.  In 
this  case  there  was  no  fluctuation.  The  cyst  wall 
was  so  dense,  and  firm,  and  strong,  that  the  only 
means  of  making  the  diagnosis  was  the  history  of  the 
case,  the  contents  as  disclosed  by  tapping,  and  bring- 
ing the  tumor  into  view  during  the  operation.  The 
exploration  of  these  tumors  is  best  performed  with  an 
extra-long  exploring  needle,  the  trocar  and  cannula, 
or  the  needle  of  the  aspirator.  Aspiration  with  a  fine 
aspiration  needle  is  perhaps  the  safest  method  of 
making  a  surgical  exploration  of  them. 


-  6^  - 

Treatment:  Instances  of  spontaneous  recovery 
have  been  reported,  but  they  have  usually  been  pre- 
ceded by  violent  rupture  of  the  ovarian  cyst,  setting 
up  inflammation,  suppuration,  etc.  Tapping  is  not 
infrequently  the  first  operation  resorted  to,  and  sev- 
eral cases  have  been  cured  by  that  simple  process. 
A  special  cannula  to  prevent  the  entrance  of  air 
should  be  used.  Drainage  by  the  ordinary  rubber 
drainage  tube,  after  tapping,  is  frequently  resorted  to. 
There  may  be  many  cases  where,  from  advanced  age 
or  feebleness  of  the  patient,  tapping  must  be  resorted 
to.  I  saw  such  a  case  last  year,  in  consultation  with 
Dr.  Chamberlin,  of  this  city.  The  patient,  77  years 
of  age  and  very  feeble,  was  tapped,  and  about  five 
gallons  of  melanotic  fluid  drawn  out.  After  six 
months  had  elapsed  the  tumor  had  not  refilled. 
About  a  gallon  of  fluid  was  removed  May,  1891. 

Incisions  have  been  practiced  and  injections  of 
iodine  given.  Peasley  announced  that  the  unilocular 
cyst  was  the  only  form  that  should  be  subject  to  in- 
cision, because  in  the  multilocular  we  cannot  get 
inflammatory  action  to  supervene  in  the  smaller  divi- 
sions, whereas  in  the  unilocular  the  inflammation 
speedily  extends  to  all  parts  of  the  sac.  Galvano- 
puncture  is  also  used;  and  finally  the  method  most 
commonly  used,  that  of  total  extirpation,  the  opera- 
tion of  ovariotomy.  I  will  not  stop  to  describe  that 
now. 

There  is  another  cyst,  known  as  parovarian  cyst, 


-  64  - 

which  I  take  up  a  little  out  of  its  regular  order  for 
convenience.  The  parovarian  cyst  originates  in  the 
small  Wolffian  bodies  which  form  the  parovarium.  Its 
symptoms,  diagnosis,  and  treatment  do  not  differ 
materially  from  those  of  the  ovarian  cyst  proper,  so  I 
shall  not  go  into  its  minute  description.  Professor 
Thomas  relates  a  case  of  cyst  of  the  broad  ligaments, 
under  which  name  the  parovarian  cyst  is  more  com- 
monly described,  in  which  ovariotomy  was  performed 
and  both  ovaries  found  entirely  normal;  so  you  will 
see  that  it  is  possible  for  the  parovarian  cyst  to  de- 
velop to  a  considerable  size  without  any  disease  of  the 
ovaries  being  present. 

Entire  removal  is  probably  the  only  treatment 
practicable.  Some  expert  microscopists  claim  that 
the  difference  in  the  contained  fluids  is  very  consider- 
able, that  of  the  broad  ligament  approaching  more 
nearly  the  ascitic  fluid  found  in  dropsy. 

We  have  still  another  variety  of  cyst — the  para- 
sitic. These  are  formed  in  consequence  ^of  the  pres- 
ence of  echinococcus,  cysticercus,  etc.,  and  are  found 
in  all  parts  of  the  body,  frequently  in  the  liver  and 
brain,  A  case  occurred  in  the  Marine  Hospital  at 
Detroit,  Mich.,  November  23d,  1882,  as  reported  by 
Surgeon  W.  H.  Long.  The  cut  shows  actual  size  of 
the  tumor. 

W.  G.  T.,  captain  of  schooner  "S.  H.  Lathrop;  " 
aged  50  years;  nativity,  New  York;  was  admitted  to 
the  United  States  Marine  Hospital  at  Detroit,  Mich.,. 


-■65  - 

November  23d,  1882,  suffering  from  hemiplegia  of 
right  side,  and  marked  aphasia. 

History:  The  patient  was  corpulent  and  weighed 
about  225  pounds.  He  was  brought  to  the  hospital  a 
few  hours  after  the  onset  of  the  attack,  which  was 
ushered  in  by  a  severe  convulsion  and  all  primary 
symptoms  of  apoplexy.  Full  doses  of  ergot  and 
potassium  bromide  were  administered,  with  friction 
over  spine  and  to  extremities.  The  patient  sank  rap- 
idly, and  died  comatose  on  the  following  day,  Novem- 
ber 24th. 

Necropsy:  When  the  skull  cap  was  removed,  the 
meninges  were  found  very  much  congested,  a  large 
quantity  of  fluid  in  the  subarachnoid  space,  and 
connective  tissue  on  surface  of  brain.  The  brain  was 
removed,  and  weighed  63  ozs.  (a  fraction  over  2,000 
grammes).  A  careful  examination  was  made  to  dis- 
cover an  extravasation  or  ruptured  artery,  but  none 
was  found.  The  brain  tissue  was  congested,  and  sur- 
face of  cerebellum  infiltrated,  but  the  ventricles  con- 
tained only  a  trace  of  fluid.  In  each  lateral  ventricle 
there  was  found  a  pedunculated  polycystic  body,  of 
an  elongated  and  ovoid  shape,  about  two  inches  in 
length  (figure  natural  size),  and  free  from  any  attach- 
ment, except  to  choroid  plexus.  They  were  lying 
loose  on  the  floor  of  each  ventricle,  and  connected 
with  one  end  was  a  long  stem  (pedicle),  which  sprang 
from  within  a  large  capillary  given  off  from  the  chor- 
oid plexus — the  attachment  above  mentioned.    These 


66   — 


ir 


c 


polycysts  were  composed  of  a  large 
number  of  cysts  of  varying  size,  and 
on  examination  by  the  microscope 
g  showed  them  as  containing  a  large 
^  number  of  small,  round  bodies  on 
o  the  mner  surface  of  the  cyst  walls; 
S  they  are  of  different  structure  from 
o  the  cysts,  as  shown  by  their  polariz- 
■g  ing,  while  the  cyst  walls  do  not.  It 
o  is  believed  they  were  echinococci. 
^  While  "  hydatid  "  tumors  containing 
t'  echinococci  are  commonly  single  in 
^  the  brain,  they  not  infrequently  occur 
g  in  groups,  each  group  having  its  ped- 
g  icle,  as  shown  in  this  specimen. 
•E  Ramda.  The  next  variety  of  these 
c  cysts  to  which  I  shall  call  your  atten- 
g  ♦  tion  is  the  so-called  ranula.  Exactly 
B  why  it  is  called  ranula  is  one  of  those 
^  things  past  finding  out.  It  comes 
B'  from  "rana,"  a  frog;  "ranula,"  a 
m  little  frog.  The  name,  is  a  very 
S  ancient  one,  and  will  have  to  stand. 
Columellus,  a  Roman  writer  on  agri- 
culture, speaks  of  a  swelling  on  the 
tongues  of  beasts  as  ranula.  .  We  have  it  as  far  back 
as  any  history  of  the  disease,  and  several  languages 
have  perpetuated  it.  Although  the  French  usually 
speak  of  it  as  grenouillette,  "a  little  frog,"  they  also 


-  67  - 

'Use  the  term  "ranule."  This  disease  is  due  to  the 
•damming  up  of  the  secretion  from  sub-maxillary  and 
sub-lingual  glands.  This  is  precisely  the  same  form 
of  cyst  that  I  described  to  you  in  speaking  of  pancre- 
-atic  cysts.  Ranula  is  sometimes  due  to  a  concretion 
blocking  up  some  of  the  ducts  or  the  main  excreting 
duct.  When  the  main  duct  becomes  occluded,  there 
is  marked  swelling  in  the  mouth,  which  will  sufficient- 
ly indicate  where  the  obstruction  is  located.  I  might 
•say  that  when  the  small  canals  are  unaffected,  and  the 
main  duct  itself  obstructed  by  a  stone,  it  is  called  a 
ptyalith.  Dermoid  cysts  in  this  region  are  sometimes 
mistaken  for  ranula,  but  the  diagnosis  is  easy  if  the 
history  of  the  case  and  the  fluid  from  the  tumor  be 
carefully  examined.  Sometimes,  indeed,  they  are  so 
enormous  that  the  patient  might  be  said  to  have  what 
Mark  Twain  describes  as  "  double  chins  all  the  way 
down  to  his  stomach."  In  these  cases  not  infre- 
quently both  the  sub-lingual  and  sub-maxillary  ducts 
are  occluded.  In  ranula,  the  patient  will  have  great 
difficulty  in  speaking,  owing  to  the  pressure  of  the 
tongue  up  towards  the  roof  of  the  mouth.  He  will 
have  this  difficulty  of  speaking,  besides  the  deformity. 
Ranula  is  almost  always  painless. 

Treatmefit:  Two  or  three  methods;  one,  little 
-used  at  present,  by  seton,  allowing  the  fluid  to  escape 
gradually  along  the  side  of  the  thread  until  an  inflam- 
matory process  has  been  set  up.  Another  method  is 
iby  excision  of  a  portion  of  the  cyst   wall.     This  has 


—  68  — 

been  done  with  scissors,  snipping  the  membrane  by 
thrusting  one  blade  into  the  tumor  and  cutting  out  a 
triangular  section;  as  soon  as  the  fluid  escapes,  the 
tincture  of  iodide  is  injected.  This  is  the  treatment 
commonly  pursued,  and  is  usually  followed  by  no 
return  of  the  tumor.  Occasionally  the  retained  saliva 
becomes  inspissated,  and  the  tumor  requires  extirpa- 
tion. 

The  next  form  of  retention  tumor — the  zuen — 
simply  refers  to  the  collection  of  sebaceous  material; 
by  the  closure  of  a  sebaceous  duct.  They  may  be 
single,  or  occur  in  groups,  and  may  follow  where 
there  has  been  any  outside  irritation.  I  have  seen 
several  cases  where  it  seemed  as  if  the  pressure  of  a 
hat  obstructed  the  sebaceous  ducts,  and  a  wen  formed 
directly  under  the  hat-band.  They  are  usually  pain- 
less, however,  and  only  annoying  on  account  of  their 
size  and  the  occasional  interference  with  wearing  the 
hat.  Treatment  is  quite  simple — that  is,  the  removal 
of  the  cystic  tumor.  On  cutting  down  through  the 
scalp  they  are  seen  as  white,  shining  tumors,  easily 
enucleated  from  the  surrounding  tissue,  and  may  be 
removed  by  the  fingers  or  scalpel  handle  without 
difficulty.  The  operation  is  followed  by  little  haemor- 
rhage. 

■  Mucocele  is  that  form  of  tumor  or  cyst  due  to 
retention  of  mucus  from  closure  of  the  duct.  It  is 
formed  wherever  there  is  mucous  membrane.  Muco- 
cele of  the  vagina  is  usually  due  to  obstruction  of  the. 


-  69  - 

vulvo-vaginal  glands.  These  mucoceles  are  irritable 
and  very  apt  to  terminate  in  suppuration.  This  is 
due,  perhaps,  to  their  anatomical  position,  which 
renders  them  liable  to  invasion  by  infective  organisms. 


LECTURE  VI. 

RETENTION  TUMORS,  CONTINUED— PROLIFER- 
ATION  TUMORS. 

I  have  not  by  any  means  exhausted  the  subject 
of  cysts.  There  is  one  other  cyst  to  which  I  shall; 
direct  your  special  attention,  and  to  which  I  referred: 
in  my  last  lecture — that  is,  the  galactocele,  or  milk 
cyst  of  the  mammary  glands.  I  used  to  think,  and  it 
has  been  frequently  taught,  that  abscess  of  the 
female  breast,  following  parturition,  was  usually  due 
to  neglect  on  the  part  of  the  accoucheur  or  the  nurse. 
But  I  am  sure  that  I'  have  seen  these  tumors  and  ab- 
scesses form  in  the  mammary  glands  where  every 
precaution  was  taken;  galactocele  formed,  followed 
by  suppuration — for  that  is  the  usual  termination^ 
of  these  cysts  of  the  mammary  glands.  They  arise- 
sometimes  by  reason  of  a  sudden  "cold,"  accom- 
panied by  a  rise  of  temperature,  and  followed  by 
a  closure  of  the  smaller  milk  ducts;  and  then,  when 
the  milk  is  dammed  up,  the  gland  will  be  enlarged  to 
a  considerable  size.  There  will  be  a  severe  rigor;  the 
patient  shakes  as  she  would  with  acute  ague.  Fever 
follows  the  chill,  and  in  a  little  while  the  tumor  is 
formed;  it  proceeds  through  the  various  grades  of 
inflammatory  action,  and  abscess  results,  due  to  in- 
flammation of  the  connective  tissue  around  the  milk 
ducts  and  subsequent  infection.     These  tumors  caa 


be  usually  prevented  by  pumping  out  carefully  the 
retained  milk  from  the  glands,  at  the  same  time  having 
the  nurse  make  gentle  pressure  both  on  the  lower  and 
upper  surface  of  the  gland,  rubbing  the  surface 
towards  the  nipple;  the  danger  is  thus  sometimes 
averted  by  the  removal  of  the  obstruction.  Then  a 
sling  may  be  placed  round  the  breast;  this  has  a 
tendency  to  prevent  any  further  accumulation,  for  it 
will  usually  be  found  that  these  accidents  occur  when 
the  patient  has  been  allowed  to  walk  around,  and 
then  the  weight  of  the  gland  and  the  accumulation  of 
milk  has  a  tendency  to  produce  obstructions.  The 
treatment  does  not  differ  from  that  of  ordinary  ab- 
scess. It  must  be  evacuated,  provided  the  milk  can- 
not be  drawn  out  through  the  natural  ducts. 

We  now  take  the  fourth  class,  or  proliferation 
tumors: 

I  St.     Fibroma: 

a.  Diffuse. 

I.     Elephantiasis. 

b.  Papillary. 

c.  Polypoid. 

d.  Tuberous. 

I.     Epulis. 

e.  Bony. 
/.     Keloid. 

The  diffuse  fibroma  is  a  sub-variety.  Then  the 
papillary  and  the  polypoid,  of  which  there  is  one 
variety,  molluscum  fibrosum,  and  the  tuberous  with 
its   variety,  the    epulis;  bony,  and    the  keloid.     Now, 


—   72   — 

recollect  that  I  mentioned  in  the  beginning  that  the 
proliferation  tumors  were  the  new  growths,  the  true 
tumors.  All  tumors,  as  I  said,  may  be  classified  into 
two  general  forms:  Neoplasms  and  cysts — neoplasms 
where  there  is  a  new.  growth,  and  cysts  where  there 
is  a  retention  of  fluid.  There  is  another  term  which 
makes  clear  the  word  proliferation,  and  that  is  vege- 
tation tumors — tumors  characterized  by  budding.  In 
their  origin  they  are  due  to  the  preliminary  stage  of 
the  inflammatory  process,  the  stage  of  irritation,  pre- 
ceding the  congestion.  The  proliferating  tumors 
exceed  in  number  those  of  any  other  of  the  four 
classes.  There  are  more  than  56  varieties  of  the  pro- 
liferation tumors  under  the  present  classification. 
They  may  grow  from  the  cartilage,  the  bone,  the  peri- 
osteum covering  the  bone,  or  from  any  tissue  of  the 
body;  and  the  substance  of  the  fibrous  tumors  may 
be  composed  of  any  one  of  these  structures.  So 
much  for  the  proliferation  tumor  in  general.  We  will 
first  take  up  that  class  of  tumors  composed  almost 
exclusively  of  connective  tissue;  that  is,  fibrous  tissue. 
The  word  fibroid  is  also  used  to  describe  the  fibrous 
tumors.  The  term  desmoid  has  also  been  proposed, 
because  of  its  resemblance  to  the  ligamentous  tissue. 
The  fibrous  tumors  are  then  to  be  considered  as 
wholly  composed  of  connective  or  fibrous  tissue. 
Sometimes,  however,  in  the  interstices  between  the 
fibres,  we  find  cartilage  cells  and  bone  cells,  or  cells  of 
any  other  natural  structure,  but  they  are  always  natu- 


—  73  — 
ral  tissue  cells.  They  may  be,  according  to  the  Vir- 
chownian  classification,  heterologous — that  is  to  say, 
a  cartilage  tumor  developed  in  a  muscle  is  a  heterolo- 
gous tumor,  because  it  is  developed  and  grows  away 
from  its  normal  situation,  although  "the  tumor  itself 
may  be  composed  of  tissue  entirely  normal — so  there 
is  no  departure  from  the  normal  type.  The  seat  of  a 
fibroma  may  be  anywhere  in  the  body.  The  uterus 
is  a  favorite  seat  of  fibroid  tumors.  I  will  not  now 
stop  to  describe  fibrous  tumors,  but  will  say  in  pass- 
ing that  they  are  very  slow  in  growth,  and  very  firm 
in  texture,  owing  to  their  structure.  They  are  also 
painless,  except  where  they  have  developed  on  the 
brain,  spinal  cord,  or  in  the  substance  of  a  nerve.  The 
fibromatous  neuromata  are  very  painful,  and  they  are 
the  only  ones  attended  by  pain.  So  much  for  the 
general  characteristics  by  which  they  may  be  recog- 
nized. When  a  particular  organ  is  involved,  there 
are  special  means  of  diagnosis  adapted  to  the  organ 
in  which  the  fibroma  is  seated.  The  first  or  diffuse 
form  is  elephantiasis.  The  seat  of  this  disease  is  in 
the  skin.  We  say  it  is  diffuse  because  in  the  more 
limited  form  it  may  be  papillary,  that  is,  enlarged 
papillae,  or  it  may  be  polypoid,  or  it  may  be  tuberous, 
the  so-called  tuberculosis  of  skin.  We  have  still  an- 
other variety  of  the  papillary  form,  known  as  the  ver- 
rucose  or  warty  fibroma.  Elephantiasis,  the  diffuse 
variety  of  fibroma,  is  a  comparatively  rare  disease.  It 
is  usually  congenital.     Small  tumors  are  formed  all 


—  74  — 
over  the  skin  of  a  particular  part.  Sometimes  it  ex- 
tends over  the  entire  body,  but  it  is  usually  confined  to 
some  particular  part,  as  the  leg,  arm,  scrotum,  vulva, 
or  neck.  It  is  conjoined  with  hypertrophy  of  the  skin, 
and  has  various  names,  according  to  the  country  where 
it  originates.  Thus  we  have  elephantiasis  Grsecorum^ 
of  the  Greeks,  elephantiasis  Arabiim,  of  the  Arabs,  etc. 
There  are  other  forms  of  elephantiasis,  which  are  said 
to  be  endemic  in  certain  countries;  elephantiasis  Grse- 
corum  and  Arabum  are  not  absolutely  confined  to 
Greece  and  Arabia,  and  hence  are  not  endemic.  The 
Barbadoes  leg — Cochin  China  leg  is  similar  to  Barba- 
does  —  for  example,  is  found  only  in  the  tropics.  The 
form  known  as  spedalsky  is  very  common  in  Norway 
and  Sweden.  All  these  forms  of  elephantiasis  are 
something  like  leprosy.  There  is,  however,  a  very 
distinct  characteristic  by  which  the  two  diseases  may 
be  recognized,  for  in  leprosy  we  have  an  exces- 
sive tendency  to  ulceration.  Moreover,  leprosy  is 
constitutional,  having  a  special  bacillus,  and  therefore 
inoculable.  There  is  no  evidence  whatever  that  ele- 
phantiasis is  contagious  in  any  degree.  It  is  most 
frequent  in  men.  Elephantiasis  commences,  when  it 
appears  on  the  scrotum  or  on  the  inferior  extremities, 
as  a  slow  inflammation.  There  is  pain,  turgescence 
of  the  skin,  and  a  tendency  to  spread;  generally  there 
is  fever,  but  not  always;  the  lymphatic  glands  are  hot, 
swollen,  and  painful,  as  well  as  the  lymphatic  ducts. 
There  is  an  exudate  — a  clear  yellowish  liquid,  which. 


—  75  — 
coagulates  slowly,  depositing  a  mass  of  fibre.  If  you 
carefully  examine  the  growth  of  complete  elephantia- 
sis, if  the  disease  can  ever  be  said  to  be  complete,  you 
will  find  that  it  consists  of  layer  upon  layer  of  the 
fibrous  element  of  the  skin,  following  an  inflammatory 
process.  It  is  true  in  elephantiasis  as  in  leprosy  that 
the  bones  become  affected.  Sometimes,  with  ele- 
phantiasis of  the  leg,  the  disease  affects  the  perios- 
teum in  such  a  degree  that  bony  osteophytes  are 
thrust  out  and  bone  forms,  so  much  so  as  to  entirely 
unite  the  tibia  and  fibula.  I  have  seen  such  a  specimen. 
The  bony  growth  had  apparently  commenced  along 
the  interosseous  membrane  on  both  sides.  In  stating 
that  one  of  the  distinctive  points  between  leprosy  and 
elephantiasis  was  that  in  leprosy  the  tendency  was 
towards  ulceration,  I  should  say  that  in  certain  hot 
countries  elephantiasis  ulcerates,  but  that  ulceration 
is  almost  entirely  local;  whereas,  in  leprosy  there  is  a 
general  contamination  of  the  system,  a  constitutional 
taint — the  patient  has  all  the  appearance  of  scrof- 
ula, and  eventually  becomes  worn  out  by  the  disease. 
Again,  leprosy  may  ulcerate  at  any  part  of  the 
body— not  alone  in  that  which  is  the  apparent  seat  of 
the  disease;  whereas,  in  elephantiasis  it  is  confined  to 
the  part  affected.  These  diffuse  forms  of  fibromata 
are  sometimes  soft,  notwithstanding  on  microscopic  ex- 
amination they  are  found  to  be  almost  entirely  connec- 
tive tissue;  yet  between  the  fibres  there  will  be  found 
a  gelatinous  substance  constituting  the  soft,  as  distin- 


-  76  - 

guished  from  the  hard,  variety.  In  the  recent  investiga- 
tions of  Manson  and  others,  the  disease  is  believed  to  be 
produced  by  the  hgematozoon  called  filaria  sanguinis 
honiinis.  Elephantiasis  of  the  scrotum  is  an  example 
of  the  soft  variety  of  this  disease.  This  is  a  very 
common  form  of  the  disease  in  China.  Elephantiasis 
of  the  scrotum  occupies  a  very  considerable  amount 
of  the  medical  reports  of  the  Chinese  Customs  medi- 
cal reports.  Sometimes  the  scrotum  grows  very  large, 
extending  down  to  the  knees —sometimes  almost  to 
the  feet.  In  such  cases  the  penis  will  be  entirely 
hidden.  The  folds  of  the  skin  over  the  organ  will 
have  grown  and  developed  until  the  penis  will  be  en- 
tirely out  of  sight.  The  testicles  cannot  be  felt.  The 
skin  will  feel  hard  and  tubercular,  and  the  patient 
will  complain  of  the  immense  weight  of  the  tumor.  A 
notable  instance  occurred  in  this  country — in  Alabama, 
I  think — where  the  tumor  was  removed,  and  did  not 
recur  after  extirpation.  In  this  disease  of  the  scrotum 
we  find  that  the  fibrous  tissue  is  almost  always  infil- 
trated with  liquid.  There  does  not  seem  to  be  much 
growth  in  the  blood-vessels,  but  rather  in  the  lymphat- 
ics. Usually  there  is  a  pigmentary  discoloration  due 
to  the  pigmentary  glands  in  the  outer  layer.  They 
become  quite  painful  through  the  weight  of  the  scro- 
tum, and  almost  always  require  extirpation.  In  oper- 
ating on  these  tumors  it  is  very  difficult  to  preserve 
the  penis.  In  the  case  of  which  a  full  report  was 
made  in  the  New  York  Medical  Journal   for   1868,  a 


—  77  — 
large  flap  was  made  directly  over  the  front  of  the 
tumor,  in  which  flap  the  penis  was  raised.  The  flap 
itself  was  about  an  inch  and  a  half  or  two  inches  long. 
A  sound  was  passed  into  the  sinus  through  which  the 
urine  had  flowed,  for  the  sinus  will  generally  indicate 
the  direction  in  which  the  penis  will  be  found.  Of 
course,  next  to  the  penis  it  is  important  to  preserve 
the  testicles.  That  is  a  matter  of  extreme  difficulty 
in  these  cases  of  great  enlargement.  In  this  case, 
however,  it  was  successfully  done,  and  the  organ  and 
its  appendages  presented  a  very  creditable  appear- 
ance. So  much  for  elephantiasis  of  the  male  organ. 
Elephantiasis  of  the  female  breast  was  known  for 
some  years  as  "  hypertrophy  of  the  breast,"  but  the 
microscope  showed  that  it  was  composed  of  this 
fibrous  structure.  They  grow  very  large  sometimes, 
so  that  the  breast  hangs  down  over  the  front  of  the 
belly — sometimes  entirely  down  to  the  knees.  The 
remedy  is  the  same  as  for  elephantiasis  of  the 
scrotum — extirpation.  Birkett  has  observed  this  dif- 
ference between  hypertrophy  of  the  natural  tissues 
and  a  tumor,  or  fibrous  growth.  He  observed  that 
true  hypertrophy  commenced  in  the  glandular  tissue, 
itself,  and  that  it  was  a  growth  of  the  organ  in  its 
entirety,  whereas  in  elephantiasis  the  growth  of  the 
tumor  was  in  the  interstitial  tissue,  between  the  glands 
and  the  integument.  The  neck  is  a  frequent  seat  of 
the  soft  or  lymphatic  form  of  elephantiasis.  vSome 
years  ago  Dr.  Carnochan,  of  New  York,  ligated  con- 


-  78  - 

secutively  the  common  carotid  artery,  right  and  left, 
and  the  patient  recovered.  The  tumor  was  very 
large.  It  involved  the  neck  on  both  sides,  so  that  the 
mouth  was  scarcely  visible,  and  the  chin  entirely  cov- 
ered up  by  the  excessive  growth  of  skin,  and  the  neck 
itself  existed  only  in  name.  It  extended  from  the 
clavicle  directly  upwards,  the  base  towards  the  clav- 
icle. The  patient  recovered.  Those  of  the  neck  are 
almost  always  of  the  soft  variety;  that  is,  where  there 
is  a  gelatinous  infiltration  of  the  fibrous  structure  of 
the  tumor. 

The  papillary  form  of  fibroma  is  simply  hyper- 
trophy of  the  papilla  in  the  beginning,  but  finally  a 
papilla  grows  out  from  the  cutis,  and  grows  very 
large.  It  is  sometimes  pedunculated;  that  is,  has  a 
foot  stalk.  It  grows  late  in  life.  It  is  not  confined, 
however,  to  the  skin,  but  is  found  sometimes  in  the 
brain,  in  the  breast,  and  in  the  bladder.  This  form 
constitutes  the  so-called  condylomata,  and  is  generally 
multiple.  There  may  be  on  the  surface  of  the  uterus 
loo  or  more.  The  polyoid  variety  is  the  fibrous  vari- 
ety as  distinguished  from  the  mucous  variety.  It  ori- 
ginates from  the  connective  tissue  lying  just  under- 
neath the  mucous  membrane,  and  pushes  the  mucous 
structure  out  with  it.  The  mucous  polypus  is  quite 
soft,  and  liable  to  bleed.  The  fibrous  polypus  does 
not  bleed.  Wherever  accessible,  the  remedy  is  extir- 
pation. One  of  the  varieties  of  polypoid  form  is  the 
molluscum  fibrosum;  that  occurs  all  over  the  body,  par- 


—  79  — 
ticularly  on  the  face,  neck,  and  trunk,  and  is  a  small 
tumor,  varying  from  the  size  of  a  pea  to  a  walnut,  quite 


Section  of  Molluscum  Fibrosum. 


—  8o  — 

moveable,  and  entirely  painless.  I  have  here  a  report 
of  a  case  made  by  Dr.  Hamlin,  of  Bangor,  Maine, 
found  in  Marine  Hospital  Report,  1882.  "He  sent  me 
the  tumor,  and  through  the  courtesy  of  some  of  my 
friends  in  the  Navy  Medical  Department,  I  had 
it  photographed.  It  is  the  only  photograph  of  that 
kind  with  which  I  am  familiar.  We  had  a  very  hand- 
some heliotype  made  from  it,  which  I  will  show  you. 

The  photograph  gives  a  pretty  clear  idea  of  the 
structure  of  the  tumors.  It  is  not  so  good  as  the  one 
in  Virchow,  but  perhaps  it  represents  a  different  sec- 
tion of  the  tumor,  this  being  transverse,  whereas  that 
of  Virchow  is  apparently  longitudinal  in  section.  A 
year  later  Dr.  Hamlin  reported  another  case.  He 
says: 

In  February,  1882,  I  had  the  honor  to  forward 
to  the  Department  the  report  of  a  case  of  molluscum, 
which  appeared  in  the  annual  report  of  the  Marine 
Hospital  Service  for  the  same  year.  On  November 
27  last,  Charles  M.  Smith  was  admitted  to  the  Marine 
Hospital  at  this  port,  suffering  from  acute  cystitis  of 
one  week's  duration.  In  making  an  examination  of 
this  patient  I  at  once  recognized  another  case  of  mol- 
luscum. Patient's  age,  42;  height,  5  feet  ^}(  inches; 
weight,  130  pounds;  figure,  spare;  birthplace,  Boston, 
Mass.  He  removed  to  this  State  (Maine)  when  a 
child,  and  performed  ordinary  coarse  labor  until 
about  20  years  of  age,  since  which  time  he  has  been  a 
sailor,  sometimes  going  before  the  mast,  at  other 
times  acting  as  steward.  His  health  had  always  been 
good  up  to  the  recent  attack  of  cystitis.     His  family 


record  revealed  no  history  of  morbid  growths  of  any 
kind.  Fifteen  years  ago  he  first  noticed  these  tumors 
on  his  face  and  neck,  and  since  then  they  have  from 
time  to  tinie  appeared  on  other  parts  of  the  body, 
causing  neither  pain  nor  discomfort.  These  growths 
were  particularly  numerous  on  the  face,  forehead, 
neck,  trunk.  They  were  fewer  in  number  on  the  ex- 
tremities, though  as  a  rule  larger  in  size;  several  on 
the  left  side  of  the  thorax,  as  well  as  one  over  the  left 
patella,  ranked  among  the  largest.  There  were  none 
on  the  scalp,  and,  excepting  one  over  the  left  instep, 
none  below  the  knees.  These  tumors  were  too  numer- 
ous to  count  accurately,  but  I  estimated  that  there 
were  about  three  hundred.  In  size  they  varied  from 
a  pin's  head  to  that  of  a  large  marble.  None  were 
pedunculated;  some  were  oval,  some  dome-shaped, 
while  others  were  nipple-like  in  form.  To  the  touch 
they  were  rather  soft  superficially,  but  fibrous  in  their 
interior.  It  would  appear  in  this  case  that  the  ten- 
dency of  the  lesions  was  to  increase  in  number,  and 
to  any  considerable  extent  in  size.  It  is  interesting 
to  note  that  the  mental  powers  of  this  individual  were 
decidedly  dwarfed.  This  patient  was  unwilling  to 
part  with  any  of  the  growths,  and  consequently  none 
could  be  obtained  to  examine  microscopically. 

These  cases  are  of  decided  interest.  I  have  m 
my  mind  now  a  medical  man  whose  face  and  necfc 
are  entirely  covered  with  these  fibroid  tumors.  There 
is  no  danger  to  health  from  any  of  the  fibromata,  with 
the  single  exception  of  the  epulis.  The  tuberous 
fibroma  may  be  the  starting  point  of  epulis.  It  is 
simply  another  form  of  the  fibrous  growths,  taking  its 
origin  from  the  skin.     For  the  most  part,  all  these 

6  WW 


—    82     — 

tuberous  fibromata  are  characterized  by  multiplicity. 
It  is  in  this  class  of  tumors  that  the  subvariety  of 
tuberous  fibroma  is  found  in  the  fibrous  epulis.  This 
is  a  small  tumor  situated  on  the  gum,  usually  spring- 
ing from  the  periosteum  of  the  socket  of  the  tooth. 
If  the  tooth  be  not  removed,  caries  follows,  and  it  is 
first  noticed  as  a  little  warty  excrescence  along  the 
side  of  the  tooth.  When  the  surgeon  is  called,  not 
infrequently  it  is  found  that  caustics  have  been  ap- 
plied, and  the  tumor  is  removed  down  to  the  gum; 
feut  its  rapid  recurrence  has  created  alarm  on  the  part 
■of  the  patient,  and  he  thinks  that  perhaps  the  growth 
is  cancerous.  But,  recognizing  that  the  tumor  springs 
from  the  socket  of  the  tooth,  it  will  be  readily  seen 
that  the  removal  to  the  level  of  the  gum  does  not 
prevent  recurrence.  The  proper  remedy  will  be  to 
remove  the  tooth,  and  scrape  out  the  tumor  from  the 
alveolus. 

There  are  numerous  forms  of  fibromata  that  are 
called  by  Virchow  "  heteroplasia,"  because  they  have 
a  tendency  to  form  different  structures  from  that  in 
which  they  grow.  For  example,  osseous  fibromata  do 
not  proceed  from  the  connective  tissue,  but  from  the 
medullary  membrane,  or  from  the  periosteum.  The 
last  form  is  the  keloid.  This  usually  occurs  after 
burns,  or  in  cicatrices.  Some  of  you  may  remember 
a  negro  who  was  a  patient  in  Providence  Hospital  a 
year  or  more  ago,  with  an  extensive  burn  of  the  neck 
and  side  of  the  shoulder.     In  every  one  of  the  scars 


-  83  - 

that  formed  by  contraction  of  the  tissiies,  a  small 
tumor  developed.  That  tumor  was  the  keloid.  It  is 
very  liable  to  recur^after  extirpation.  It  is  non-ma- 
lignant in  character,  and  should  cause  the  patient  no 
annoyance  except  to  appearance.  I  have  seen  a  great 
many  of  these  keloid  growths  growing  from  the  lobe 
of  the  ears  after  piercing  for  ear-rings. 


)tL^ 


Figs.  3-4. — Photograph  of  an  unusual  tumor  of   the  thigh  (from 
a  Marine  Hospital  patient).     Front. — [Dr.  Glennan.] 


The  same  patient.     Back. 


LECTURE  VII. 

PROLIFERATION  TUMORS,  CONTINUED. 

CLASS    4.       LIPOMA,    MYXOMA,    CHONDROMA,    ENCHON- 
DROMA,    OSTEOID    ENCHONDROMA. 

By  the  term  lipoina  we  mean  a  fatty  tumor,  that 
is  to  say,  a  tumor  composed  of  normal  fat.  There 
was  once  a  term  used — steatoma — to  designate  this 
class  of  tumors,  but  they  were  confounded  with  seba- 
ceous tumors,  and  there  is  a  great  difference  between 
them.  The  sebaceous  cyst  is,  as  you  will  remember,, 
a  retention  tumor.  It  is  due  to  retention  of  sebum. 
There  is  usually  no  cholesterin  in  the  fatty  tumor — 
whereas  in  steatoma  there  is  cholesterin.  Lipomata  are 
composed,  then,  of  true  fatty  tissue.  "  The  fat  is  con- 
tained in  cells  with  membrane  surrounding  it,  which 
cells  are  generally  identical  with  the  ordinary  fatty 
tissue  and  contain  the  fat  crystals,  but  they  are  larger 
than  the  fat  of  the  adipose  tissue  which  they  join  "  ( Vir- 
chow).  They  are  always  proliferation  tumors;  that  is 
to  say,  they  vegetate  from  neoplasms.  "  Every  lipoma. 
is  lobulated;  that  is,  contains  lobules  between  which  are 
formed  the  connective  tissue  and  vessels  "  (Virchow). 
In  ordinary  lipoma,  a  small  fatty  tumor,  the  fat  greatly 
predominates  over  the  connective  tissue  lying  between 
the  lobes.     But  we  have  several  varieties;  the  fibrous- 


—  87   — 
(for  one),  where  the  connective  tissue  predominates. 
The  lobes  are  smaller  than  in  the  ordinary  variety. 
We  may  have  still  another  form  of  lipoma — teleangei- 
ectatic— where   there   is   an   increase  in  the  number 
and  size  of  the   blood-vessels.     Then  we  have   the 
"  petrified  "   lipoma— a  calcareous  degeneration,  and 
an  osseous  form.     Finally,  we  have  the  epiploic  lipo- 
ma, which  is  lipomatous  hernia,  so-called,  where  the 
epiploon  has  passed  out  through  the  hernial  opening, 
and    fatty    degeneration   or   proliferation    has    com- 
menced.    Lipomata  are  also  named  from  their  shape. 
Thus   we   have   polypoid  lipoma;   that  is  where  the 
tumor  has  a  foot  stalk   connected  with   the  tissue. 
Then  we  have  the  arborescent,  arranged  like  leaves 
on   the   branches   of    a    tree.      These    tumors   may 
extend   into    the    serous   and   synovial    membranes. 
So  much  for  the  normal  varieties.     We  have  also  the 
so-called  sclerous  form,  where  there  is  hardening  and 
induration.     Sometimes  cartilage  cells  are  thrown  out 
and  form  one  of  the  so-called  cartilaginous  tumors, 
part  fat  and  part  cartilage.    Sometimes  it  takes  on  cre- 
taceous degeneration.  The  outer  layer  becomes  almost 
as  calcareous  as  a  calculus  in  the  bladder.     Finally,, 
we  have  fatty  tumors  in  the  parenchyma  of  the  organs. 
We  find  them  in  the  liver,  in  the  kidneys,  and  in  the 
brain.     Ordinarily  the  lipoma  is  a  single  tumor,  but 
occasionally  you  will  find   a  patient  who  has  several 
tumors  in  different  parts  of  the  body,  but  they  seem 
to  have  no  connection  with  each  other.     Ordinarily, 


©besity  will  possibly  degenerate  into  fatty  tumor 
whenever  it  projects  beyond  the  body  so  that  the  skin 
is  forced  out  and  the  fat  is  no  longer  in  layers,  or 
there  is  an  extra  deposition  of  the  fat  and  it  becomes 
encapsulated — ^^then  it  is  a  tumor.  But  there  is  tliis 
differen(?e;  let  the  patient  be  put  on  low  diet,  starva- 
tion diet,  if  you  please,  and  the  fat  which  is  connected 
with  the  general  circulation,  and  is  deposited  in  the 
natural  places,  will  be  taken  up,  and  the  patient  will 
become  less  stout,  whereas  in  lipoma  no  amount  of 
starvation  will  diminish  the  size  of  the  growth.  As  to 
the  progress  of  the  tumor:  Inflammation  is  somewhat 
rare;  it  is  painless,  and  its  growth  is  slow.  Occasion- 
ally, however,  from  weight  and  pressure  of  the  cloth- 
ing, inflammation  of  adjacent  tissues  will  result.  It  is 
usually  in  mild  degree,  but  occasionally  may  progress 
to  the  formation  of  pus,  ulceration,  or  even  gangrene, 
from  obstruction  of  the  blood-vessels  going  to  the 
tumor.  In  the  ordinary  lipoma,  especially  where  it  is 
in  a  prominent  place,  you  will  find  that  the  skin,  if  it 
is  rubbed  through,  causes  an  ulcer.  I  have  seen  a 
lipoma  over  the  buttock  of  a  young  man  22  years  of 
age.  There  was  an  opening  into  it  where  the  skin 
seemed  to  have  been  rubbed  through,  about  the  size 
of  a  silver  dollar,  through  which  the  fatty  structure 
could  be  distinctly  seen.  It  was  painless,  and  through 
it  exuded  a  serous  exudation.  That  tumor  would 
weigh  perhaps  25  pounds,  but  he  was  unwilling  to  let 
it  go,  it  having  been  his  constant  companion  for  many 


years;  I  could  not  persuade  him  to  part  with  it  at  the 
time,  and  I  lost  sight  of  him.  The  treatment  of 
lipoma  is  extirpation,  no  remedy  having  been  found 
that  will  exercise  the  slightest  influence  over  its  pro- 
gress or  retard  its  growth.  The  diseased  skin  should 
be  removed  with  it,  and  every  prolongation— every 
lobule — should  be  removed,  otherwise  there  may  be  a 
recurrence.  The  next  form  of  tumor  is  the  myxoma, 
a  semi-malignant  tumor,  to  which  an  asterisk  has 
been  affixed  in  the  nomenclature,  so  that  you  may 
know  that  tumors  having  that  mark  are  either  malig- 
nant/.?/-  se,  or  may  become  so  from  situation. 

Myxomata  are  the  mucous  tumors.  They  differ 
from  the  mucous  cysts,  for  which  you  might  confound 
them  if  your  attention  were  not  directed  to  them,  in 
this:  The  mucous  cyst  is  simply  an  obstruction  of  a 
mucous  gland,  whereas  myxoma  is  composed  strictly 
of  mucous  tissue.  It  is  not  a  cyst,  but  a  vegetative  or 
proliferative  tumor.  These  tumors  are  all  soft  and 
painful.  They  differ  from  the  fibroma,-  in  that  they 
are  composed  less  of  connective  tissue  than  of  mucous 
tissue,  and  they  do  not  impart  that  hard  feeling  that  is 
found  in  the  fibromata.  Sometimes  we  have  fluctua- 
tion in  them;  that  is,  where  the  mucous  glands  have 
been  stimulated,  secretion  increased,  and  mucus  ac- 
cumulated. The  myxomata  are  very  frequent  in  the 
eye.  We  have  them  in  that  situation  as  the  "hyaline." 
They  may  be  seen  sometimes  in  the  aqueous  humor, 
and  are  harmless.     I  think  Virchow  terms  them  het- 


—  90  — 

erologous;  but  they  are  true  mucous  tissue,  although 
technically  heterologous.  We  term  it  medullary 
myxoma  where  the  myxoma  starts  from  the  medullary 
membrane.  When  a  myxoma  liquefies,  we  term  it 
cystoid,  because  it  is  like  a  cyst,  although  not  a  true 
cyst.  Whenever  the  connective  tissue  predominates 
over  the  mucous  tissue,  it  is  then  termed  fibrous  myx- 
oma; and  when  fat  globules  predominate,  it  is  called 
lipomatous.  When  the  cartilaginous  prevails,  it  is 
called  cartilaginous  myxoma.  So  it  is  with  the 
increase  of  blood  vessels,  when  it  is  termed  teleangei- 
ectatic.  Then  there  is  the  myxoma  peculiar  to 
females.  We  have  a  myxoma  of  the  placenta,  which 
was  formerly  called  cavernous  mole,  and  hydatids  of 
the  placenta,  but  is  now  known  as  myxoma.  The 
heterologous  myxoma  may  be  developed  in  any  organ 
or  tissue  of  the  body.  The  nerve  sheaths  are  very 
common  sites  for  myxoma,  the  neuromatous  variety. 
I  have  spoken  of  the  fibrous  tumor  of  the  nerves,  the 
neuroma,  so-called.  There  is  also  a  myxomatous 
neuroma  composed  of  mucous  structure,  which  gives 
rise  to  as  much  pain  as  the  fibrous  neuroma.  The 
diagnosis  of  myxoma  is  always  uncertain  before 
removal.  It  usually  requires  a  microscopical  exami- 
nation to  determine  the  nature  of  this  tumor. 
Usually  it  does  not  recur  after  extirpation,  but  occa- 
sionally it  does,  and  then  it  generally  assumes  the  so- 
called  malignant  form.  The  tumor  may  not  be  mal- 
ignant in  its  incipiency.     It  may  not  be  malignant  in 


—  91   — 

most  of  its  growth;  but  sometimes  a  change  in  the 
cells  commences  and  a  marked  departure  in  the  type 
of  its  issue,  and  then  the  tendency  to  destroy  life  is. 
developed. 

Chondroma.  There  are  three  varieties  of  chon- 
droma: The  ecchondroma,  the  enchondroma,  and 
the  osteoid  enchondroma.  The  ecchondroma  is  a 
tumor  arising  directly  from  the  cartilage.  The 
enchondroma  rises  from  the  connective  tissue,  the 
bone,  or  periosteum.  We  have  the  ecchondroma 
most  frequently  in  the  larynx  and  trachea,  springing 
from  the  cartilage;  if  on  the  internal  aspect,  they 
speedily  destroy  life  by  obstruction  of  breathing,  un- 
less extirpated.  We  find  it  also  in  the  symphysis 
pubis,  where  it  grows  to  a  great  size.  Also  in  the 
spheno-occipital  articulation  in  the  early  period  of 
life,  springing  from  the  edges  of  the  fontanelle. 
Death  results  from  perforation  of  the  dura  mater. 
Then  we  have  enchondroma  of  the  intervertebral 
cartilages,  and  from  the  occipital  cartilages.  We 
have  in  the  chondroma,  as  well  as  the  myxoma  and 
lipoma,  the  so-called  heterologous  growths.  Ecchon- 
droma may  also  grow  directly  from  the  inter-articular 
cartilage  of  the  joint.  In  the  first  year  of  my  prac- 
tice I  had  a  case  of  enchondroma  on  the  finger  of 
the  right  hand  of  a  farmer,  who  said  the  swelling  was 
caused  by  the  plow  handle.  He  consulted  several 
practitioners,  and  a  great  many  diagnoses  had  been 
given.     I  advised  the  removal  of  the  tumor.    On  cut- 


—   92  — 

ting  down  I  found  a  tough,  white,  dense,  fibro-carti- 
laginous  structure,  springing  from  the  periosteum. 
The  patient  recovered,  and  the  tumor  did  not  recur. 
I  had  recently  a  case  of  a  private  patient  in  Provi- 
dence Hospital,  where  the  tumor,  about  the  size  of 
a  walnut  and  distinctly  cartilaginous,  developed  on 
the  right  thigh,  springing  from  the  fascia  lata.  The 
cartilage  cells,  you  remember,  are  from  ^w  ^^  two 
inch  in  diameter.  The  tumor  gave  him  consid- 
erable pain  by  rubbing  against  his  clothing,  and 
was  in  the  way  of  his  hand  when  he  put  it  in  his 
pocket.  He  said  he  almost  invariably  struck  tne 
tumor.  It  was  removed  with  some  difficulty,  owing 
to  its  fibrous  connective  tissue  attachments.  Enchon- 
droma,  or  I  may  say  chondromata  in  general,  are 
generally  non-malignant,  but  they  occasionally  recur 
after  extirpation.  Mussey  reported  a  case  some  years 
ago  where  ertchondroma  commenced  in  the  hand, 
which  was  amputated.  It  followed  in  the  arm,  which 
was  amputated,  and  finally  proceeded  to  the  shoulder 
of  the  patient,  who  lost  his  life.  Syme  had  a  case 
where  the  shoulder  was  amputated  for  enchondroma 
of  the  arm,  and  it  recurred  in  the  stump  and  in  the 
axilla.  Virchow  reports  a  case  of  enchondroma  of 
the  scapula  where  the  tumor  was  removed  seven 
times,  and  the  patient  finally  recovered.  The  remedy 
for  this  tumor  is  extirpation.  The  next  variety  is 
osteoid  chondroma.  This  is  composed  of  osteoid 
tissue,  but  is  more  properly  classed  as  an  osteo-sar- 


—  93  — 
coma.     There   is  great  vascularity  in   these    osteoid 
enchondromata,  and  extirpation  is  the  only  remedy. 
In  these  tumors,  wherever  the  bone  is  involved,  am- 
putation is  the  only  remedy. 


LECTURE  VIII. 

PROLIFERATION  TUMORS,  CONTINUED. 

'OSTEOMA,  PSAMMOMA,  MELANOMA,  MYOMA,  NEUROMA, 
ADENOMA,  DERMOID  CYST,  ANGEIOMA. 

Osteoma. — The  next  variety  of  tumor  is  the 
osteoma,  or  bone  tumor  proper.  We  have,  first,  the 
•eburnated  osteoma,  where  the  bone  is  harder  than 
normal;  it  diiTers  from  bone  in  the  apparent  absence 
oi  blood-vessels  and  cancellous  tissue;  the  bony 
<;anals  have  become  obliterated  by  the  hardening  pro- 
cess. We  have  in  some  cases  the  cancellous  or 
spongy  osteoma,  which  merely  differs  from  the  other 
bony  tissue  by  being  a  hyperplasia  of  the  normal  can- 
cellous structure,  simply  an  increase  of  growth.  We 
classify  into  exostosis,  hyperostosis,  and  osteophytes. 
Exostosis  of  the  bone  is  an  extra  deposition  of  osse- 
ous particles,  which  grow  in  an  irregular  shape. 
Sometimes  the  bone  becomes  one-third  larger  than 
normal.  Now  that  is  entirely  homologous — that  is, 
like  the  normal  bone.  We  have  the  heterologous 
class  of  osteomata  in  what  are  termed  osteophytes. 
That  is  where  the  bony  structure  is  developed  away 
from  the  bone.  These  osteophytes  usually  grow 
from  the  articular  cartilages,  cartilage  cells  being 
formed  with  the  true  bony  structure.  Sometimes 
•they   grow  from   the  connective  tissue,  but  usually 


—  95  — 
from  the  cartilage.  Rarely  we  find  them  growing 
after  a  fracture.  There  is  what  is  termed  the  bony 
or  ossific  diathesis;  that  is,  a  tendency  to  produce 
bone  anywhere.  We  find  it  occasionally  in  chronic 
rheumatism  of  the  articular  variety,  and  in  gout. 
This  form  rarely  falls  under  the  observation  of  the 
surgeon  unless  it  becomes  so  large  as  to  inconvenience 
the  patient.  Odontoma  is  a  term  applied  to  an  exos- 
tosis composed  of  dentine  growing  from  the  cement 
of  a  tooth. 

Psammoma,  the  brain  sand-tumor,  so-called  be- 
cause it  is  apparently  composed  of  a  granular  black 
substance  called  brain  sand,  is  found  principally  in 
the  choroid  plexus,  and  in  the  dura  mater.  This 
black  cerebral  sand  is  also  found  in  the  lymphatic 
glands,  or  complicating  other  tumors  by  forming  in 
their  substance,  and  it  may  occur  in  various  forms. 
It  is  now  known  that  these  tumors  contain  spindle 
cells,  and  are  hence  classed  among  the  sarcomata; 
Woodhead  called  them  "angiolithic  sarcomata." 
Sometimes  when  they  grow  very  large  on  the  choroid 
plexus  or  dura  mater,  they  produce  pressure,  and  then 
the  usual  cerebral  symptoms  will  manifest  themselves. 
This  is  one  of  the  tumors  wrongly  placed  in  our  classi- 
fication. 

Melanoma.  We  call  this  the  seventh  variety  of 
proliferation  tumor.  It  is  the  pigment  tumor  of  the 
meninges.  It  is  to  be  carefully  distinguished  from 
melanotic  cancer,  which  is    a    pigment    encephaloid 


-  96  - 

(medullary  cancer).  Now  this  melanoma,  more  prop- 
erly a  melanotic  sarcoma,  occurs  primarily  in  the  pia 
mater,  and  in  the  choroid.  It  occurs  also  in  the 
fascia,  and  in  the  membranes  of  the  spinal  cord,  and 
in  the  nervous  centres  of  the  body.  In  addition  to 
the  choroid,  we  may  find  it  in  the  iris,  in  the  con- 
junctiva, and  the  skin.  In  fact,  melanoma  occurs 
most  frequently  in  those  tissues  in  which  pigment  is 
the  normal  constituent.  There  is  hypertrophy  of  the 
pigment  glands,  and  hyperplasia  of  the  pigment  cells. 
When  it  contains  spindle  cells  we  term  it  melano- 
sarcoma,  and  it  is  then  the  most  malignant  of  all  the 
sarcomatous  grewths. 

Myoma.  This  tumor  is  composed  entirely  of 
muscular  structure.  Both  kinds  of  muscular  fibres, 
the  striated  and  non-striated,  enter  into  it,  so  that  we 
find  it  in  both  the  voluntary  and  the  involuntary 
muscles.  When  the  tumor  is  composed  of  striped 
muscular  tissue,  it  is  termed  rhabdomyoma,  and  when 
of  unstriped  muscular  tissue,  it  is  called  leiomyoma. 
Where  there  is  a  great  abundance  of  connective  tissue 
in  the  myoma,  it  gives  rise  to  great  difficulty  in  diag- 
nosis between  myoma  and  fibroma.  Where  thus  mixed^ 
the  tumor  is  called  myo-fibroma.  These  tumors  are 
non-malignant,  and  entirely  homologous.  They  fre- 
quently have. haemorrhage  as  one  of  their  symptoms,, 
due  to  a  rapid  growth  and  to  the  weight  of  the  tumor. 
It  is  a  passive  haemorrhage.  It  also  sometimes  takes 
on  cystic  degeneration,  where  the  tumor  is  broken 


—  97  — 
down.  We  may  have  the  occurrence  of  teleangeiectasis 
where  the  tumor  contains  an  excessive  number  of 
anastomosing  capillaries  or  blood  vessels.  They  are 
sometimes  cavernous  and  sometimes  varicose.  Car- 
cinoma occasionally  takes  the  place  of  myoma.  The 
tumor  then  becomes  infiltrated  with  epithelial  cells, 
and  as  the  disease  departs  from  the  normal  type  by 
displacement  and  degeneration  of  the  muscle  cells, 
becomes  true  carcinoma;  so  it  is  scarcely  proper 
always  to  say  to  a  patient  afflicted  with  myoma  that 
it  is  non-malignant,  as  there  is  a  possibility  of  the 
carcinomatous  substitution.  The  liability  to  this  sub- 
stitution is  admitted,  but  on  account  of  that  liability, 
however  limited,  it  is  better  to  give  your  prognosis 
with  exceeding  care.  The  most  common  seat  of 
myoma  is  in  the  uterus,  and  in  that  situation,  owing 
to  the  greater  abundance  of  connective  tissue  between 
the  muscle  cells,  it  takes  the  form  of  myo-fibroma. 

The  diagnosis  is  a  matter  of  considerable  diffi- 
culty. They  are  comparatively  slow  in  growth,  which 
distinguishes  them  from  carcinoma.  They  are  com- 
paratively painless;  another  point  where  they  may  be 
distinguished  from  malignant  tumors,  which  are  gen- 
erally painful.  The  diagnosis  of  this  tumor  from 
ovarian  cyst,  which  is  also  painless,  and  of  slow 
growth,  can  only  be  made  by  the  history  of  the  case, 
the  general  symptoms,  and  conjoined  manipulation. 
In  ovarian  cyst  the  swelling  will  have  been  first 
noticed  in  the  iliac  fossa — in  the  majority  of  cases  in 


—  98  - 

the  left  iliac  fossa.  Now,  myo-fibroma  of  the  uterus 
is  usually  directly  in  the  centre,  behind  the  bladder. 
Sometimes,  if  upon  the  anterior  wall  of  the  uterus, 
there  will  be  great  difficulty  in  retaining  the  urine  in 
the  bladder.  A  myomatous  tumor  sometimes  be- 
comes affected  by  cystic  degeneration,  and  then  we 
have  fluctuation,  so  that  it  will  be  almost  impossible 
during  the  life  of  the  patient  to  make  an  accurate  diag- 
nosis. These  tumors  frequently  project  in  the  cavity 
of  the  womb,  springing  from  the  tissues  of  the  interior 
wall  (intra-mural).  In  such  cases  removal  by  instru- 
ment is  practicable.  This  is  best  done  by  enucleation,  a 
process  very  similar  to  taking  an  onion  out  of  its  skin. 
Various  enucleators  have  been  invented,  the  number 
of  which  is  a  very  good  sign  that  there  is  still  room 
for  improvement.  Professor  Thompson  has  invented 
a  spoon  saw.  To  reach  the  tumor,  the  cervix  must  be 
dilated  until  the  cavity  of  the  womb  can  be  reached 
with  ease.  Dr.  Yarrow  has  an  enucleator  which  is  a 
claw-shaped  spoon  with  a  cutting  edge.  It  is  passed " 
into  the  tumor,  which  is  gradually  gnawed  away. 
Emmett  had  one  like'  a  thimble,  and  the  operation 
was  done  entirely  by  manipulation  with  the  finger. 
In  case  of  uterine  myoma,  where  there  is  great  haem- 
orrhage, and  the  recurrent  periods  are  characterized 
by  menorrhagia  and  great  ovarian  pain,  it  has  some- 
times been  found  necessary  to  perform  Tait's  or 
Battey's  operation  for  removal  of  the  ovary.  It  is 
well  to  bear  in  mind  that  menstruation  does  not  im- 


—  99  — 
■mediately  cease  on  removal  of  the  ovary,  even  when 
the  Fallopian  tubes  have  been  removed. 

Now,  when  these  myomata  are  attached  to  the 
external  wall  of  the  uterus  and  the  connective  tissue 
to  such  an  extent  that  they  gradually  crowd  out  the 
muscle-cells,  and  become  in  time  a  true  fibromata  or 
fibroid  of  the  uterus.  The  treatment  has  always  been 
very  unsatisfactory.  The  treatment  by  electrolysis 
according  to  the  method  of  Apostoli  is  still  sub  Judice, 
but  as  between  that  method  and  the  more  heroic  one 
of  hysterectomy,  prudence  would  indicate  first  a  trial 
-of  the  former,  leaving  hysterectomy  for  the  derniei- 
ressort. 

The  next  class  of  tumor  is  the  Neuroma.  Neuro- 
mata are  composed  entirely  of  nervous  tissue.  Now, 
4on't  make  the  mistake  of  calling  the  fibrous  tumor 
or  fibroma  which  occurs  in  the  nerve-shaft  a  neuroma. 
You  should  make  the  broad  distinction  that  the  neur- 
oma proper  is  composed  of  nervous  tissue.  In  speak- 
ing of  fibroma  I  told  you  that  there  was  a  tumor 
which  developed  upon  the  nerve  itself  which  was  very 
painful  and  essentially  a  fibroma — that  is,  fibrous 
"neuroma"  in  which  the  nerve-fibres  may  be  seen 
unchanged  passing  through  the  mass  of  hypertrophied 
■connective  tissue — but  it  differs  absolutely  from  true 
neuroma,  which  is  composed  entirely  of  nerve  struc- 
ture. This  neuroma  occurs  most  commonly  after 
amputation  when  the  nerve  is  cut  across.  The  Pen- 
sion Office  records  are  full  of  cases  where  the  pen- 


sioner  is  unable  to  wear  an  artificial  limb  on  account 
of  the  great  pain  or  neuralgia  in  the  stump.  This  is 
usually  due  to  enlargement  of  the  nerve  from  neuritis. 
Of  course  it  is  highly  sensitive.  There  is  usually  but- 
one  available  remedy,  excision  of  the  neuroma,  which 
will  generally  cure  the  patient.  Sometimes  it  may  be 
practicable  to  divide  the  nerve  above  the  tumor. 
These  irritable  stumps  may  sometimes  be  very  effec- 
tually treated  by  dividing  all  the  tissues  to  the  end  of 
the  bone-stump.  Neuromata  never  recur  after  re- 
moval. Irritable  stumps  may  frequently  be  prevented;; 
by  taking  care  during  the  amputation  to  pull  the  nerve 
and  divide  it  as  high  up  as  practicable. 

Neuroma  may  also  be  caused  by  bruises.  Pro- 
fessor Kleinschmidt  had  a  case  in  this  city  a  few 
years  ago  in  which  I  was  called  to  make  an  opera- 
tion, where  the  supra-orbital  nerve  had  been  wounded. 
A  man  had  been  struck  by  a  beer-glass  on  the  supra- 
orbital nerve,  finally  resulting  in  most  agonizing  recur- 
rent attacks  of  neuralgia  at  the  seat  of  the  injury,- 
On  examination  it  was  found  that  the  eyebrow  had 
been  badly  torn.  A  swelling  of  the  size  of  a  lead, 
pencil  could  be  felt  in  the  cicatrix.  A  longitudinal 
incision  was  made  at  the  margin  of  the  orbit,  the  lid 
drawn  down,  and  the  nerve  exposed.  It  was  flat- 
tened and  spread  over  a  considerable  surface,  three- 
times  its  normal  size.  It  was  removed  as  far  as  pos- 
sible; the  pain  disappeared,  and  has  never  returned., 
So  far  as  I  know,  that  is  the  general  course  of  neuro- 


ma  proper.  Where  we  have  facial  tic,  which  is  a  dis- 
ease of  the  dental  nerve,  sometimes  of  centric  origin, 
^ue  to  ganglionic  changes,  a  resection  of  that  nerve 
does  not  cure  the  patient,  because  it  does  not  appear 
that  there  has  been  an  increase  of  nerve-tissue  at  the 
point  where  the  pain  is  most  acute.  It  seems  to  be  a 
longitudinal  inflammation  of  the  entire  nerve-sheath, 
so  that  removal  of  a  section  of  that  nerve,  while 
affording  temporary  relief,  does  not  cure  the  disease. 

In  tic-douloureux  the  removal  of  a  section  of  the 
inferior  dental  nerve  will  usually  cure  the  patient  for 
five  or  six  months.  After  that  it  recurs,  though  some 
cases  are  on  record  where  the  patients  have  been  free 
from  pain  for  two  years — but  I  think  the  invariable 
history  is  that  it  returns.  Lately  Mr.  Rose,  of  Eng- 
land, and  Professor  Andrews,  of  Chicago,  have  pro- 
posed the  excision  of  the  Gasserian  ganglion.  The 
operation  was  successfully  performed  by  Mr.  Rose. 

Adenoma  is  a  gland  tumor — composed  of  glandu- 
lar structure.  We  may  find  adenoma  in  any  gland  of 
the  body,  from  the  pineal  down  to  the  lymphatics.  It 
is  proper  to  say,  however,  that  in  the  gland  tumor,  or 
adenoma,  there  are  a  variety  of  mixed  forms;  adeno- 
sarcoma,  which  is  produced  by  the  admixture  of 
sarcomatous  cells  with  the  gland  structure  proper; 
adeno-myxoma,  which  is  a  gland  tumor  with  mucous 
cells  intermixed.  Under  our  classification  the  mucous 
polypi  were  classed  as  adenomata  because  they  were 
supposed  to  be  a  hypertrophy  of  the  mucous  glands, 


but  it  is  now  taught  that  they  are  really  fibromata^ 
They  originate,  according  to  Hamilton,  of  Aberdeen,. 
"  in  the  fibrous  tissues  of  the  mucous  membrane,  and 
grow  in  the  direction  of  least  resistance,  namely,  intO' 
the  cavity  which  the  mucous  membrane  lines.  It 
pushes  the  epithelium  in  front  of  it,  and  insinuates 
itself  between  the  glands  of  the  membrane."  They 
may  grow  in  any  part  of  the  mucous  membrane.  They 
are  quite  soft  to  the  touch;  sometimes  translucent^ 
sometimes  pale  or  opalescent.  This  is  the  ordinary 
polypus  of  the  nares,  the  uterus,  and  the  external 
auditory  meatus;  as -will  be  seen,  it  is  wrongly  placed 
in  the  classification.  The  diagnosis  of  the  adenoma 
proper  is  very  difficult.  It  is  especially  so  when  the 
adenoma  is  in  an  inguinal  gland,  when  the  question 
whether  the  disease  is  due  to  syphilis  or  specific  in- 
fection of  some  kind  will  arise.  The  only  means  of 
diagnosis  in  such  cases  is  the  history  of  the  case,  and 
if  the  patient  is  inclined  to  prevaricate,  you  will  be 
obliged  to  have  recourse  to  anatomical  consideration. 
Of  course  it  is  easy  to  tell  bubo  from  an  antecedent 
gonorrhoea,  or  chancre  from  adenoma.  Bubo  is  above 
Poupart's  ligament,  and  adenoma  is  below  it.  Differ- 
ential diagnosis  between  adenoma  and  cancer  is  very 
important  and  very  difficult.  So  far  as  the  patient  is 
concerned,  the  remedy  will  usually  be  the  same — ex- 
tirpation. But  it  is  a  great  thing  to  be  able  to  tell  the 
patient  that  the  disease  is  non-malignant.  Now,  in 
adenoma  of  the  mammary  gland  you  should  always. 


—    ;o3  — 

treat  it  like  cancer,  for  fear  of  carcinomatous  prolif- 
eration. 

There  is  another  variety  of  adenoma,  known  as 
molluscutn  contagiosum,  so-called  because  it  was 
formerly  believed  to  be  contagious.  It  is  a  homolo- 
gous epidermic  growth.  It  is  situated  in  the  gland 
adjacent  to  the  hair  follicle,  and  is  sometimes  called 
epithelial  molluscum,  because  it  is  situated  in  the 
sebaceous  glands.  Virchow  states  that  this  tumor 
does  not  show  the  fatty  glands  or  oil  globules,  found 
in  sebaceous  tumors.  Owing  to  the  great  number  and 
variety  of  the  mollusca,  extirpation  is  hardly  worth 
considering,  as  they  involve  so  great  an  extent  of  sur- 
face. They  are  precisely  like  molluscum  fibrosum, 
so  far  as  distribution  over  the  body  is  concerned.  It 
is  now  believed  that  the  former  growth  is  due  to  a 
micro-organism. 

Dermoid  Cyst.  This  is  not  a  true  cyst,  because  it 
is  not  due  to  damming  up  of  any  duct.  These  cysts 
contain  sebum,  the  cells  of  epidermis — that  is,  pave- 
ment epithelium — and  the  walls  of  the  cyst  are  usually 
like  true  skin.  Sometimes  these  tumors  contain  hairs^ 
sweat-glands,  teeth,  etc.,  and  the  products  of  these 
glands  are  retained  in  the  cysts,  and  add  to  their  size 
and  keep  the  growths  constantly  increasing.  The 
hair  found  in  these  cysts  is  sometimes  very  long  and 
in  great  bunches.  This  is  produced  by  the  hair  fol- 
licles found  in  the  cyst  wall.  Teeth  are  sometimes 
found    in    them,  encased    in   bone.     Sometimes   the 


—   I04  — 

teeth  are  loose.  The  reason  why  it  has  been  classed 
as  a  proliferating  tumor  is  because  of  the  growth  of 
these  dermoid  appendages.  It  is  nearly  always  con- 
genital, but  it  was  formerly  supposed  that  the  der- 
moid cyst  was  due  to  an  undeveloped  foetus.  This 
is  disproved  by  very  many  things,  one  of  which  is 
that  as  many  as  one  hundred  teeth  have  been  found 
in  one  cyst — enough  teeth  for  a  great  many  foetuses. 
It  is  usually  found  in  the  ovaries,  and  the  treatment 
is  the  same  as  for  other  ovarian  cysts;  it  has  also 
been  found  in  the  orbit  of  the  eye,  in  the  testicle,  and 
in  the  mouth. 

Angeioma  is  a  tumor  composed  mainly  of  newly- 
formed  blood-vessels,  or  of  blood-vessels  with  newly- 
formed  elements  in  their  walls.  We  have  the  simple 
angeioma,  the  cavernous,  venous,  arterial,  and  mu- 
cous. The  names  will  give  you  an  indication  of  the 
pathology  of  that  form  of  tumor.  Simple  angeioma 
is  an  enlargement  of  all  the  blood-vessels  of  the  part 
constituting  the  tumor.  Cavernous  angeioma  is  ap- 
plied to  that  form  where  the  vessels  are  greatly  dilated, 
the  form  usually  taken  on  by  nsevus,  or  mother's  mark. 
The  sub-varieties  of  cavernous  are  arterial,  venous, 
and  mucous.  The  simple  angeioma  is  a  vascular 
tumor,  from  which  comes  the  term  Teleangiectasis. 
The  common  seat  of  the  angeioma  is  the  face  and 
neck.  You  may  often  see  patients  on  the  street  with 
the  simple  variety,  the  growth  spreading  over  the  en- 
tire cheek,  or  any  part  of  the  skm  of  the  face.     They 


—  I05  — 

are  best  treated  by  subcutaneous  ligation.  They  are 
also  treated  by  cauterization  and  by  electrolysis. 
Angeiomata  are  occasionally  coexistent  with  sarcoma. 
A  sailor  came  to  me  Feb.  2 2d,  1877,  having  an  immense 
angeioma  directly  between  the  shoulders,  over  the 
spine.  It  projected  considerably  beyond  the  surface, 
and  was  congenital,  but  lately  had  given  him  some 
pain  by  reason  of  its  increased  size.  I  passed  a 
needle  directly  through  it,  with  a  double  ligature,  in 
one  direction,  and  another  at  right  angles,  also  armed 
with  a  double  ligature.  The  ends  were  then  cut,  and 
the  tumor  tied  in  four  sections.  It  came  off  in  a  few 
days,  the  cicatrix  healed,  and  the  man  apparently 
recovered.  After  I  left  the  station  I  was  informed 
that  the  man  returned  in  a  few  weeks  with  an 
immense  sarcomatous  growth  in  the  axilla,  of  which 
he  finally  died,  so  that  the  prognosis  after  removal  of 
this  tumor  is  not  always  favorable. 

The  cutaneous  naevi  on  the  face  and  other  parts 
are  best  removed  by  the  red-hot  needle  thrust  into 
them  subcutaneously,  cauterizing  with  the  galvanic 
needle  from  an  8-  or  lo-cell  battery.  When  the  eschar 
is  formed  by  the  cautery,  you  must  allow  it  to  become 
perfectly  hard  and  dry.  Electrolysis  is  a  favorite 
method  of  treatment.  The  operation  is  performed  as 
follows:*  "One  or  more  steel,  platinum,  or  irido- 
platinum    needles   are   connected  with   the   negative 


*  Shoemaker,  Diseases  of  Skin,  p.  48.     ist  ed. 


—   io6  — 

pole  of  the  battery,  and,  if  the  iisevus  be  large,  one 
needle  or  a  charcoal  point  with  the  positive  pole;  both 
needles  are  introduced  at  the  same  time  into  the 
growth,  and  allowed  to  remain  in  the  tissue  for  a  few 
moments  until  gas  bubbles  ascend  through  the  orifice, 
a  clot  forms,  and  the  spot  assumes  a  blueish-white 
color.  The  negative  needle  is  first  removed.  The 
current  being  reversed,  the  positive  becomes  the 
negative  needle,  and  is  easily  removed." 

The  still  more  superficial  forms  are  often  treated 
by  subcutaneous  ligation,  the  knot  known  by  the 
English  surgeons  as  Ferguson's  being  that  usually 
employed. 

Then  there  is  the  linear  scarification;  done  by 
making  lines  of  scarification  in  one  direction,  and 
then  crossing  them  at  right  angles.  Then  there  i& 
the  puncture.  A  number  of  needle-points  are  thrust 
directly  into  these  surfaces.  Sometimes  vaccination 
has  been  used  to  destroy  these  tumors  where  the  pa- 
tient has  not  been  vaccinated.  The  virus  is  inserted 
directly  into  the  angeioma,  and  a  cure  is  said  to^ 
result. 


LECTURE  IX. 

PROLIFERATION  TUMORS,  CONTINUED. 

PAPILLOMA,   GLIOMA. 

Continuing  the  subject  of  proliferation  tumors,  I 
will  speak  of  the  papilloma^  which  is  the  15th  in  order 
of  the  4th  class: 

a.  Wart. 

b.  Mucous  tubercle. 

c.  Condylomata. 

d.  Urethral  caruncle. 

The  papilloma  consists  of  hypertrophied  and 
branched  papillae,  and  always  occurs  in  one  of  the 
three  surfaces,  cutaneous,  mucous,  or  serous.  The 
first  one  of  this  variety  is  the  common  wart — the  so- 
called  verruca  vulgaris,  which  is  simply  an  enlarge- 
ment of  the  papilla.  There  are  various  forms  of 
them,  such  as  the  verruca  senilis,  which  is  the  wart 
of  the  old  people,  usually  situated  on  the  back,  and 
highly  pigmented;  verruca  filiformis,  a  very  small  fili- 
form wart,  \\.o  \  inch  in  length,  painless,  and  looking 
much  like  a  piece  of  thread  projecting  from  the  skin, 
and  which  can  sometimes  scarcely  be  detected  except 
by  attempting  to  pull  it  off;  a  flat  form  called  verruca 
plana;  moist  warts,  from  which  a  constant  secretion 
is  produced.  The  cause  of  the  wart  is  not  known. 
Virchow  states  that  anatomy  bears  out  the  statement 


—  io8  — 

that  it  is  simply  an  enlargement  of  the  papilla. 
Sometimes  they  disappear  spontaneously.  This  fact 
is  taken  advantage  of  by  charlatans  and  so-called 
''cancer  doctors;"  all  forms  of  warts  being  called 
cancers,  and  subjected  to  all  sorts  of  cauterizations, 
and  among  the  negroes  to  Voudooism.  The  child's 
remedy  of  a  pencil  mark  around  the  growth,  oint- 
ments, and  a  variety  of  applications  are  in  popular 
repute  as  wart  cures.  Some  are  amusing,  and  a  re- 
cital of  them  would  make  an  interesting  chapter. 
Warts  may  be  treated  by  snipping  them  off  with  scis- 
sors, or  cauterizing  with  nitric  acid.  The  mucous 
tubercle  is  another  form  of  papilloma,  being  an  en- 
largement of  the  mucous  papilla.  Sometimes  it  takes 
on  softening  and  general  cystic  degeneration,  and  in 
that  way  the  duct  becomes  obstructed,  and  we  have 
a  mucous  cyst  resulting  from  an  originally  verrucous 
growth. 

The  condyloma  is  a  form  that  is  deserving  of  con- 
siderably more  attention.  There  is  a  general  predis- 
position to  the  formation  of  papillary  growths  in  the 
inter-natal  fold,  in  the  groin,  and  in  fleshy  females 
where  the  mammary  glands  hang  over  the  chest,  and 
anywhere  where  mucous  or  cutaneous  surfaces  rub 
against  each  other.  The  condyloma  appears  not 
only  from  natural  causes,  but  is  frequently  and  usu- 
ally due  to  a  specific  cause.  We  find  it  on  the  glans 
penis  and  the  corona  glandis.  There  is  a  considera- 
ble  secretion    flowing   from   them,    which    is   highly 


—  log  — 

odoriferous  and  disagreeable.  Tliere  is  great  irrita- 
tion when  it  is  situated  in  the  glans  penis,  or  concealed 
beneath  the  prepuce,  and  there  may  be  pain,  not 
directly  from  the  condyloma  itself,  but  from  the  irri- 
tation caused  to  the  prepuce  and  gland.  When  con- 
cealed, it  may  be  mistaken  for  gonorrhoea  or  a  con- 
cealed ulcer.  The  operation  for  phimosis  will  reveal 
at  once  the  cause  of  the  difficulty;  or  by  using  a  pair 
of  forceps,  as  a  speculum,  the  prepuce  may  be  sepa- 
rated so  that  the  growth  may  be  seen.  The  treat- 
ment is  excision  with  the  knife  or  cautery,  or,  as  I 
prefer,  the  actual  cautery,  or  fuming  nitric  acid.  The 
next  form  is  urethral  caruncle.  When  this  is  large,  it 
constitutes  a  very  serious  affection.  It  consists  of 
enlarged  papillae  situated  at  the  meatus  urinarius  of 
the  female,  and  sometimes  entirely  within  the  urethra. 
Anatomically  these  structures  are  found  to  be  very 
richly  endowed  with  nerve  filaments  and  blood-vessels, 
on  account  of  which  they  are  very  painful  and  bleed 
very  freely.  Not  only  that,  but  they  sometimes  form 
a  considerable  obstruction  to  the  flow  of  urine,  mak- 
ing urination  painful.  Cases  are  recorded  where  the 
caruncle  has  attained  the  size  of  a  goose-egg,  though 
ordinarily  they  are  the  size  of  a  pea.  When  they  are 
found  in  the  urethral  canal,  instead  of  the  margin  of 
the  meatus,  they  give  rise  to  greater  obstruction  to 
the  flow  of  urine,  and  necessitate  the  passage  of  the 
catheter;  a  very  painful  operation. 

<•   The  prognosis  is  good  if  single,  but  if  multiple 


they  produce  persistent  neuralgia  of  the  membranes, 
so  that  the  removal  of  the  caruncle  does  not  stop  the 
pain,  and  you  must  give  a  guarded  prognosis  in  such 
cases. 

Treatment:  To  remove  them,  you  may  use  the 
ordinary  polypus  snare,  or  excise  them  by  scissors,  or 
use  the  thermo-cautery.  If  situated  in  the  canal,  it 
will  be  necessary  to  dilate  the  urethra  and  apply  a 
stick  of  nitrate  of  silver  or  fuming  nitric  acid,  by 
means  of  a  glass  rod,  to  the  stump  of  the  tumor.  For 
the  persistent  neuralgia  following  these  carunculi, 
forcible  dilatation  of  the  urethra  is  the  best  remedy. 

'^Glioma.  Following  the  nomenclature,  I  shall  fix  to 
glioma  an  asterisk  to  denote  that  it  is  malignant.  As 
its  etymology  would  indicate,  it  is  a  gelatinous  tumor. 
Virchow  gave  the  name  to  this  tumor,  which  comes 
from  the  gelatinous  substance  between  the  nerve 
proper  and  the  connective  tissue  of  the  nerve;  the 
gelatinous  substance  of  Rolando.  This,  you  will  re- 
member, differs  from  the  neuroglia  proper  (the  con- 
nective tissue  of  the  spinal  cord).  The  tumor  is 
found  most  frequently  on  the  retina  and  choroid. 
Williams  states  it  is  the  only  tumor  of  the  retina;  but 
other  forms  of  sarcomata  are  frequently  found  among 
the  intra-ocular  tumors.  It  is  highly  malignant,  and 
invariably  destroys  life.  An  operation  may  prolong 
but  does  not  save  life.  It  was  formerly  termed  en- 
cephaloid,  but,  as  I  shall  show  you  in  speaking  of 
encephaloid,  there  is  a  very  marked  and  wide  differ- 


ence  between  glioma  and  encephaloid.  Occasionally 
we  have  glioma  of  the  mucous  surfaces,  or  springing 
from  the  nerve;  again,  we  have  them  intermixed  with 
mucous  structure — myxo-gliomata.  Gliomata  on  the 
serous  surfaces,  the  arachnoid  for  example,  are  harder 
than  these,  which  are  always  soft.  The  former  ap- 
proach to  the  fibroma,  and  are  sometimes  called  from 
that  circumstance  fibro-glioma.  It  is  now  claimed 
that  the  glioma  is  a  variety  of  the  round-celled  sar- 
coma^the  view  adopted  by  the  most  recent  patholo- 
gists. It  is,  I  may  say,  a  disease  almost  entirely  of 
early  life,  very  seldom  occurring  in  the  adult,  and  in 
this  respect  markedly  different  from  ordinary  sarcoma. 
Sometimes  the  gliomata  have  branching,  spider-like 
cells,  called  Dieter's  cells.  These  tumors  may  take 
on  calcareous  or  fatty  degeneration.  On  looking  into 
the  pupil  of  a  child  affected  with  glioma,  we  find  a 
white,  glistening  appearance,  sometimes  called  the 
"  cat's  eye."  There  is  great  tension  and  great  pain. 
Sometimes  after  the  eye  has  been  enucleated  we  find 
that  the  disease  has  extended  along  the  optic  nerve 
and  into  the  substance  of  the  brain;  occasionally  it 
breaks  out  afresh,  extending  to  the  soft  structures  in 
the  orbit.  In  the  American  Journal  of  Medical  Sciences 
for  October,  1884,  I  find  a  case  reported  by  my  friend 
Dr.  Dickey,  of  Wheeling,  which  is  so  typical  that  I 
shall  take  up  your  time  by  reading  it: 

Virginia ,  a  bright,  attractive  child  of  very 

fair  and  beautiful    complexion,  when  two   years  old 


was  found  to  be  entirely  blind  in  the  left  eye.  The 
pupil  was  widely^  dilated,  and  through  it  shone  a 
satiny,  lemon-colored  reflex.  There  was  some  ptosis 
and  convergent  strabismus.  None  of  the  vessels 
were  congested,  nor  had  there  ever  been  any  evidence 
of  pain.  The  growth  ^was  probably  congenital,  for 
shortly  after  birth  the  child's  aunt  had  noticed  some- 
thing peculiar  about  the  eye,  and  in  a  picture  taken 
at  three  months  can  be  observed  a  slight  degree  of 
ptosis  and  deflection  inward  and  upward. 

The  little  patient  was  examined  by  several  prom- 
inent surgeons  and  oculists  of  Philadelphia,  where  the 
family  then  lived,  and  enucleation  was  advised.  The 
operation  was  performed  successfully  a  few  months 
later,  and  there  was  never  any  recurrence  in  the  left 
eye.  Six  months  afterward  vision  began  to  fail  in  the 
right  eye,  and  the  child  was  taken  to  Philadelphia — 
the  family  having  removed  to  this  city  in  the  mean- 
time— but  an  ophthalmoscopic  examination  revealed 
nothing  but  a  slightly  congested  condition  of  the 
retina.  In  the  following  fall  vision  had  entirely 
failed,  the  ball  being  constantly  turned  upward  in  a 
vain  effort  to  see.  The  pupil  gradually  became 
dilated,  and  the  same  salmon-colored  reflex  could  be 
observed  that  had  been  noticed  in  the  other  eye.  The 
tumor  gradually  grew  until  it  could  be  easily  seen  in 
a  good  light  at  the  distance  of  several  feet.  It 
appeared  to  be  lobular  in  form,  and  tortuous  vessels 
traversed  its  surface.  These  were  plainly  visible  as 
the  refracting  media  retained  their  transparency. 
The  pupil  became  dilated  ad  maximum^  tension 
increased,  the  scleral  vessels  were  congested,  and 
attacks  of  sharp  pain  became  frequent.  An  operation 
was  deemed  advisable,  and  on  January  15th,  with  Dr. 
R.  W.  Hazlett  and  Dr.  E.  L.  Hoge,  I  removed  the 


—   113  — 

globe.  We  found  the  optic  nerve  considerably  thick- 
ened, and  resected  it  as  far  back  as  possible,  remov- 
ing some  of  the  orbital  cellular  tissue  about  the  nerve. 
We  made  a  microscopical  examination  of  the  eye,  and 
found  the  sclerotic  coat  near  the  ciliary  region  verf 
thin  and  almost  ready  to  burst.  The  vitreous  humor 
had  degenerated  into  a  dirty,  watery  fluid  full  of  float- 
ing specks  of  caseous  matter.  On  the  back  wall  of 
the  eye,  with  the  papilla  as  a  centre,  was  a  tumor  the 
size  and  shape  of  a  Lima  bean.  The  specimen  was 
sent  to  Dr.  Knapp,  of  New  York,  who  kindly  ex- 
amined it  microscopically,  and  reported  that  it  was  a 
well  characterized  glioma  of  the  retina,  spreading  to 
the  surrounding  choroid  by  a  cake-like  transition. 

There  was  a  speedy  recovery  from  the  operation, 
but  on  March  ist,  about  six  weeks  after  the  enuclea- 
tion, the  tumor  reappeared  in  the  right  orbit,  and 
grew  rapidly,  pushing  out  between  the  lids.  It 
assumed  a  cylindrical  form,  and  extended  from  the 
orbit  about  six  inches,  with  a  circumference  of  about 
nine  inches.  The  tumor  was  covered  with  the  stretched 
integument  of  the  lids  out  to  the  end,  where  it  pre- 
sented a  rough,  fungous,  bleeding  surface,  which 
eventually  became  quite  offensive,  having  the  heavy, 
peculiar  odor  of  an  open  cancer.  The  growth  hung 
downward  by  its  own  weight,  projecting  so  far  as  to 
make  it  difficult  for  the  little  sufferer  to  drink  from  a 
cup,  and  pressing  upon  the  nose  until  the  right  nostril 
was  occluded,  and  the  left  considerably  obstructed. 
The  cervical  glands  became  very  much  enlarged, 
especially  on  the  affected  side,  and  the  inguinal  glands 
of  both  sides  were  indurated.  Several  metastatic 
tumors  formed  on  the  head,  the  first  one,  which  ap-\ 
peared  in  the  lambdoidal  portion  of  the  occipital  bone, 
attaining  the  size  of  a  hen's  egg.     The  other  tumors, 

8  WW 


—   iM  — 

ranging  in  size  from  a  hazel  nut  to  An  English  walnut, 
were  on  the  parietal  bones.  They  were  quite  hard, 
and  were  probably  caused  by  metastases  in  the  diploe, 
as  described  in  Case  i,  and  illustrated  in  Figures  lo, 
II,  and  12,  in  Knapp's  work  on  Intra-ocular  Tumors. 
The  patient  gradually  grew  weaker,  finally  be- 
coming greatly  emaciated,  and  died  of  exhaustion, 
July  25th,  1884,  four  years  and  three  months  old, 
about  a  year  and  a  half  after  the  first  enucleation,  and 
about  six  months  after  the  second.  She  retained  full 
consciousness  to  the  last.  There  was  entire  absence 
of  cerebral  symptoms  through  the  whole  course  of 
disease.  The  child  was  an  unusually  intelligent  one, 
and  at  no  time  was  there  perceptible  dullness  of  in- 
tellect. A  post-mortem  examination  could  not  be  ob- 
tained. 

I  read  this  case  in  detail,  because  it  gives  you  a 
better  idea  of  the  growth  and  progress  of  glioma  than 
hours  of  lecturing  on  obscure  conditions  of  that  kind. 


LECTURE  X. 

PROLIFERATION  TUMORS,  CONTINUED— GRAN- 
ULATION  TUMORS. 

TUMORS  DUE  TO  INFECTIVE    MICRO-ORGANISMS;    LUPUS, 

GUMMA,  LEPRA  ARABUM,  YAWS,  GLANDERS, 

LYMPHOMA. 

Granulation  tumors— the  15th  variety  of  class  4 
— are  all  due  to  micro-organisms.  First  there  is 
•simple  granulation;  then  lupus;  then  gumma;  lepra 
Arabum;  yaws;  farcy  or  glanders;  and  tubercle  proper 
— that  is,  granulation  tubercle.  This  form  of  tumor 
is  characterized  by  a  tendency  to  formation  of  granu- 
lations, having,  however,  great  affinity  to  the  sarcom- 
atous tumors.  They  are  by  some  included  among 
the  round-celled  sarcomata.  Virchow,  who  gave 
their  name,  admits  the  great  difficulty  in  distinguish- 
ing them  from  sarcomata.  They  are  characterized 
iby  inflammatory  action,  and  differ  from  the  ordinary 
products  of  inflammation  by  infectivity,  and  a  failure 
to  complete  the  process  of  repair.  They  should  be 
■classed  among  the  microbic  diseases.  They  are 
wrongly  placed  among  the  proliferation  tumors  in  our 
nomenclature. 

Lupus^  as  the  name  would  indicate,  is  a  corrod- 
ing tumor — an  eating  tumor — from  "lupus,"  a  wolf. 
We  find  it,  however,  in  two  forms — '"'exedens"  and 


—  ii6  — 

non-exedens.  The  lupus  non-exedens  sometimes, 
cicatrizes  and  heals  spontaneously,  but  the  other 
variety  does  not.  Friedlander,  in  1874,  first  suggested 
that  lupus  was -a  tubercular  disease,  and  Koch  subse- 
quently (1882)  demonstrated  the  tubercle  bacilli  in 
some  specimens.  It  is,  therefore,  a  tuberculosis  of  the. 
skin.  Its  frequent  seat  is  the  nose;  commencing  at 
the  external  opening  of  the  nasal  duct,  it  extends 
down  the  side  of  the  nose  into  the  interior  nasal  pass- 
ages, destroying  the  entire  nose,  lips,  eyelids,  and 
the  soft  tissues  of  the  face.  I  remember  an  old  physi- 
sician  who  lived  a  short  distance  from  my  boyhood' 
home.  I  remember  how  all  the  children  ran  awa5r 
when  he  came  on  the  scene.  Although  the  disease 
had  then  ceased  to  progress,  he  presented  an  appear- 
ance not  only  disgusting,  but  horrifying.  His  lips, 
nose,  and  eyelids  were  gone,  and  the  mouth  was- 
simply  a  ghastly  opening,  from  which  the  saliva 
flowed,  dribbling  over  the  deformed  chin,  and  the 
lachrymal  secretion  went  dribbling  down  over  the 
front  of  the  raw  face.  His  teeth  were  still  left,  the 
gums  sound,  and  by  his  teeth  he  was  able  to  retain  a 
handkerchief  to  catch  the  salivary  flow;  and  so  he 
walked  about  for  many  years.  Finally,  secondary 
lymphatic  infection  of  a  malignant  form  intervened- 
and  destroyed  his  life.  Lupus  does  not  always  de- 
stroy life;  sometimes,  instead  of  occurring  on  the  face,. 
as  in  the  case  i  have  just  described,  it  occurs  on  the 
hand,  or  it  may  be  on  any  portion   of  the  skin.      It 


—  117  — 

■closely  resembles  syphilis,  and  in  the  form  of  "  Ltipus 
syphilitica,''  which  is  really  syphilis,  the  two  may  be 
confused  and  the  syphilis  be  treated  for  lupus;  it  is 
very  painful.  It  may  be  mistaken  for  epithelial  can- 
cer, and,  if  the  disease  is  not  recognized  and  properly 
treated,  will  destroy  life. 

The  treatment  for  lupus  is  the  actual  cautery  or 
fuming  nitric  acid,  to  destroy  the  granulations  and 
the  specific  character  of  the  ulcer;  or  by  any  of  the 
more  common  forms  of  caustic,  one  of  the  best  being 
pure  bromine,  mopping  it  on  the  diseased  tissue. 
Bromine  is  said  to  almost  certainly  arrest  the  progress 
•of  the  disease.  Mercury  as  an  internal  remedy  may 
be  administered  in  combination  with  iodide  of  potas- 
sium, or  in  the  form  of  protiodide  of  mercury,  or  cor- 
rosive chloride.  Treatment  by  injection  of  "  tuber- 
culin "  has  proved  a  failure.  I  have  seen  the  most 
marked  changes  occur  in  the  lupus  ulcer  after  the  in- 
jection of  the  "tuberculin,"  but  at  the  date  of  revising 
this  proof  I  have  not  seen  any  case  of  recovery  from 
its  use. 

Gumma.  This  is  not  malignant,  and  is  amenable 
to  treatment,  so  much  so  that  medication  alone  usu- 
ally suffices.  It  is  a  soft,  fluctuating  tumor,  due  to  the 
bacillus  of  syphilis.  It  is  rather  a  circumscribed  de- 
generative change  than  a  new  growth.  The  gumma 
may  be  found  on  the  periosteum  of  the  long  bones, 
and  in  the  soft  tissues.  The  brain,  the  liver,  and  the 
spleen    and   the   kidney  are   not   infrequent  seats  of 


—  ii8  — 

gummata.  When  the  gummy  tumor  springs  from  the 
periosteum,  you  will  generally  find  that  the  patient 
complains  of  nocturnal  pains,  and  that  the  generaii 
symptoms  of  periostitis  are  present. 

The   treatment   consists   in  the  external   use  of 
iodine  ointment  and  "  mixed  "  treatment  internally. 

Lepra  Arabum.  This  "  leprosy  of  the  Arabs"  is  also* 
called  elephantiasis  Grsecorum,  but  it  differs  from  the 
fibrous  elephantiasis  already  described;  first,  as  to  its 
inoculability;  and  second,  as  to  its  anatomy.  Some 
claim  that  it  is  not  inoculable,  but  the  lepra  Arabum^ 
or  true  leprosy,  is  in  its  nature  essentially  contagious,, 
being  caused  by  an  infective  organism.  There  is  a  ten- 
dency to  ulceration.  From  time  immemorial  the  leper 
has  been  excluded  from  the  society  of  his  fellows,, 
and  most  recent  investigators  have  decided  that  the 
segregation  of  the  leper  is  a  necessary  precaution. 
The  report  of  the  health  officer  of  the  Kingdom  of 
Hawaii  shows  that  there  are  two  islands  set  apart  for 
lepers  — one  for  leprosy  which  has  not  proceeded  to 
ulceration,  and  one  for  lepers  who  have  reached  the 
ulcerative  stage.  On  reading  the  report  I  was  struck,  in. 
the  first  place,  by  the  extreme  care  with  which  a  home 
is  provided  for  that  unfortunate  class  of  people,  and  the 
great  desire  to  prevent,  if  possible,  the  further  spread 
of  the  disease.  In  Norway;  in  Maracaibo,  Venezuela; 
and  in  Havana,  Cuba,  there  are  special  institutions  for 
the  treatment  of  lepers;  there  is  also  a  leper  settlement 
in  New  Brunswick.     A  few  cases  were  reported  in 


—  119  — 
Louisiana,  and  some  in  Minnesota,  mainly  among  the 
Norwegians,  who  probably  brought  the  disease  with 
them.  It  has  not  been  known  to  develop  or  materi- 
ally spread  in  this  country,  but  in  New  Brunswick  I 
believe  the  disease  is  spreading;  it  certainly  is  in 
Norway;  and  in  the  Hawaiian  Islands  the  leper  popu- 
lation is  believed  to  be  increasing.  The  bacillus  of 
leprosy  demonstrated  by  Dr.Arman  Hansen,  of  Bergen, 
in  1873,  resembles  that  of  tubercle;  these  bacilli  are 
very  numerous.  Unna  states  that  an  examination  of 
one  of  the  leprous  tubercle^  shows  that  almost  the 
larger  half  of  the  tissue  consists  of  bacilli  and  their 
products.  Leprosy  is  incurable  at  present,  although 
much  is  hoped  from  the  new  studies  in  bacteriology. 

Symptoms:  There  is  sometimes  pain  present,  and 
in  the  beginning  there  is  usually  hypergesthesia  of  the 
part.  The  swollen  tubercles  are  quite  painful,  but  as 
the  disease  progresses,  the  nerves  are  impinged  upon 
so  that  they  are  not  capable  of  transmitting  secretion. 
Then  ansesthesia -follows.  I  have  twice  visited  the 
Leper  Hospital  in  Havana,-  and  made  careful  inspec- 
tions of  the  inmates.  All  varieties  and  stages  of  the 
affection  may  be  seen  at  this  hospital;  cases  where 
the  patients  are  totally  blind  from  destructive  ulcera- 
tion of  the  eyes,  those  without  fingers  and  toes,  and 
those  with  tuberculated  faces  are  most  common.  The 
series  of  photographs  sent  the  Marine  Hospital  Bureau 
by  the  U.  S.  Consul  at  Maracaibo  are  most  interest- 
ing.    Leprosy  is  slower  in   its  course  than  syphilis. 


A  leper  may  live  for  years,  but  when  the  disease  pro- 
gresses to  ulceration,  if  not  before,  there  is  fever, 
which  is  persistent,  and  daily  exacerbations. 

Treatment :  The  general  treatment  is  most  un- 
satisfactory. The  Chinese  remedy  is  the  Hoang  Nan. 
Analgesin  for  the  febrile  symptoms  is  said  to  have 
been  administered  with  good  effect.  Then  we  have 
Chaulmoogra  oil,  and  the  Gurjun-wood  oil.  The 
Hoang  Nan  is  the  bark  of  a  tree  of  the  Strychnos 
family,  and  is  said  to  owe  its  curative  property  to  the 
strychnine  and  brucine,*  in  small  quantities,  which  it 
contains.  Of  course,  such  patients  should  be  promptly 
isolated. 

Yaivs,  also  called  framboesia,  is  a  disease  of  the 
West  Indies  and  tropical  islands,  and  endemic  in  the 
mountains  of  Peru.  It  is  also  known  as  Peruvian  ver- 
ruga. The  disease  has  a  febrile  stage  and  an  erup- 
tive stage.  When  the  eruption  appears,  the  tumor 
grows  until  it  reaches  the  size  of  a  raspberry;  some 
remain  about  the  size  of  a  currant.  The  accompany- 
ing illustration  from  Dr.  Nielly's  Elements  de  Patho- 
hgie  Exotique  shows  very  clearly  the  appearance  of 
these  eruptive  growths.  Yaws  also  grows  in  the  cuta- 
neous folds,  in  the  wrinkles  of  the  neck,  axilla,  groin, 
and  in  those  places  in  which  condylomata  appear.  It 
first  occurs  in  small,  reddish  spots,  which  are  hsemor- 
rhagic;  they  enlarge,  and  finally  ulcerate.  The  dis- 
ease is  contagious,  and  the  exudation  from  it  inocu- 
lable.     It  is,  however,  amenable  to  treatment. 


Treatment:  In  the  first  place  the  tumors  should 
be  excised  or  cauterized,  and  the  febrile  symptoms 
controlled  by  appropriate  medication.  In  Peru  de- 
scent from  the  mountain  is  insisted  upon,  and  general 
tonics  are  administered. 


Glanders  or  Farcy.  This  is  a  disease  specific  in 
character,  which  may  be  transmitted  to  man  from  the 
lower  animals,  most  frequently  the  horse,  the  mule, 
or  the  ass.  Man  himself  may  reciprocate  that  favor 
by  retransmitting  the  disease  to  an  animal  previously 
sound.  It  is  one  of  the  most  contagious  diseases 
known,  but  Professor  Senn  asserts  that  the  virus  of 
glanders  can  only  find  entrance  into  the  organism 
through  a  wounded  surface.  It  has  its  most  frequent 
seat  in  the  mucous  membrane  of  the  nose.  The 
membranes  become  swollen,  and  the  Schneiderian 
membrane  becomes  involved;  after  a  while  there  is  a 
nodular  eruption  of  the  skin,  "  farcy  buds,"  which 
finally  ulcerate;  and  high  fever  is  present.  There  is 
great  swelling  of  the  glands,  generally  the  axillary 
and  those  of  the  neck  and  ears.  The  bowels  are 
costive,  and  there  is  general  malaise.  The  bacillus 
peculiar  to  glanders  is  called  the  bacilhis  Mallei.  In 
the  treatment  of  these  cases  great  care  must  be  taken 
to  prevent  the  disease  being  carried  to  yourself  and 
attendants.  The  period  of  incubation  is  very  short, 
the  disease  setting  in  actively  two  or  three  days  after 
breathing  the  contaminated  air  or  inoculation  by  the 
virus.  Pustules  are  seen  in  about  ten  days  after  the 
beginning  of  the  disease.  When  the  disease  is  exter- 
nal, and  the  internal  organs  are  not  involved,  the  pa- 
tient may  recover,  but  glanders  is  one  of  the  most 
fatal  maladies.  It  has  been  noted  that  the  glands 
are  swollen  and  sometimes  change  the  same  as  in 


—    123   — 
oriental   plague,  which  causes  a  swelHng  of  all  the 
glands   of   the   body,    and    hence   has   been    termed 
bubonic  plague. 

Treatment;  The  treatment  of  glanders  has  been 
very  unsatisfactory,  and  death  generally  takes  place 
in  from  one  to  three  weeks.  Of  course,  if  called  to 
such  a  case,  the  most  active  local  disinfection  should 
be  practiced.  From  the  beginning  the  mercuric 
bichloride  solution  should  be  mopped  upon  the  nasal 
membrane,  the  glands  themselves  being  injected  with 
a  dilute  solution  of  carbolic  acid  or  bromine.  The 
attendants  and  surgeon  should  have  their  hands  care- 
fully oiled,  and  every  precaution  taken  so  far  as  quar- 
antining the  patient  is  concerned.  Treat  the  case  as 
you  would  when  there  is  an  asthenic  tendency  requir- 
ing quinine  and  tonics,  basing  your  highest  faith  on 
local  disinfection. 

*  Lymphoma.  This  is  the  lymphatic  tissue  tumor, 
and  usually  malignant.  These  are  neoplasms  of  the 
connective  tissue.  Now,  this  tissue  is  found  in  every 
tissue  of  the  lymphatic  glands,  and  also  in  the  Mai- ' 
pighian  corpuscles  of  the  spleen,  in  Peyer's  patches, 
the  glands  of  Lieberkiihn,  the  thymus  gland,  and  the 
glands  of  the  pharynx.  You  will  see,  then,  that  the 
lymphatic  system  is  composed  of  glands  and  lacunae,  or 
•'  lymph  spaces"  and  fibrillae;  these  last  are  the  con- 
nective tissue  of  the  lymphatics.  The  fibrillae  form  a 
net-work,  and  between  the  meshes  of  the  net-work 
are  the  so-called  corpuscles.     Lymphoma  would  seem 


124    — 

to  be  a  hyperplasia  or  outgrowth,  or  proliferation  of 
normal  lymphatic  tissue.  In  that  peculiar  disease 
known  as  Hodgkin's,  the  lymphatic  glands  through- 
out the  body  are  infected.  T.ymphomata  are  usually 
non-malignant,  but  epithelial  cells  are  sometimes  infil- 
trated from  the  adjoining  tissue,  and  the  more  rapidly 
they  proliferate,  the  more  malignant  the  tumor.  Some- 
times they  are  simple  hyperplasias — non-malignant.  It 
should  be  remembered  that  there  is  some  variation  in 
lymph  tissue  structure  in  health,  but  when  the  cells 
are  atypical  then  they  become  malignant.  The  cells 
are  like  those  of  small  round  celled  sarcoma.  Lym- 
phoma of  the  mammary  gland  is  as  fatal  as  any  carci- 
noma. In  Hodgkin's  disease  the  spleen  is  found  to 
be  diseased  in  four-fifths  of  the  cases.  The  Hodg- 
kin's disease  has  been  termed  by  Mr.  Paget  lymphatic 
adenoma;  but  as  it  is  a  specific  disease,  it  is  very 
doubtful  if  it  should  be  included  in  lymphoma  proper. 
Simple  lymphoma  is  very  difficult  to  diagnosticate  from 
adenoma.  Owing  to  the  character  of  the  cells  and  the 
stroma,  some  consider  it  a  sarcoma  of  the  lymphatics, 
and  others  term  one  variety  of  it  lymph-sarcoma. 


LECTURE  XI. 

PROLIFERATION  TUMORS,  CONTINUED. 


SARCOMA. 


Sarcoma.  The  disease  known  as  sarcoma  is  one 
of  the  most  important  of  the  tumors,  whether  we  con- 
sider its  variety  of  forms,  its  effects  on  the  patient,  or 
the  attention  that  must  be  given  by  the  surgeon. 
Among  the  older  writers,  nearly  all  malignant  and 
fleshy  tumors  of  whatever  character  were  included 
among  the  sarcomata,  and  I  am  not  sure  but  you  may 
conclude,  when  considering  the  number  of  tumors 
that,  having  separate  names,  are  yet  classed  among 
them,  I  am  fast  returning  to  the  ancient  practice. 
This  tumor  is  generally,  but  not  always,  malignant. 
The  initial  growth  of  the  sarcoma  is  from  the  con- 
nective tissue,  in  whatever  organ  or  tissue  the  tumor 
may  be  found;  but  there  is  a  cellular  structure  in  the 
sarcoma  in  addition  to  the  type  cell  of  the  matrix  from 
which  it  sprung.  The  cells  are  infiltrated  between  the 
fibrillee  of  the  connective  tissue.  The  starting  point 
may  be  normal  connective  tissue,  or  that  of  another 
tumor,  such  as  myoma,  fibroma,  or  cyst.  The  sarcoma 
springing  from  the  connective  tissue  then  becomes  a 
myo-sarcoma,  a  fibro-sarcoma,  or  a  cysto-sarcoma; 
and  that  is  what  is  meant  by  the  sarcomatous  trans- 
formation.    The  cells  of  a  sarcoma  are  the  formative 


126    

cells  of  connective  tissue,  but  they  never  complete 
the  formation;  hence  they  are  termed  embryonic. 
This  holds  true  of  all  varieties  of  sarcomata;  and 
these  embryonic  cells  are  constantly  reproduced  in 
the  proliferation  growth  of  the  tumor.  There  are 
three  broad  varieties  of  sarcomata.  The  first  has  a 
simple  or  round  cell,  and  is  the  most  malignant;  the 
next  has  the  so-called  giant  cell;  and  the  remaining 
one  the  spindle  cell.  The  giant  cells  have  also  been 
"termed  myeloid,  because  they  are  like  the  protoplasms 
found  in  the  marrow  of  foetal  bones.  They  are  the 
largest  of  all  human  cells.  They  sometimes  have 
hundreds  of  these  nucleated  cells;  these  may  have  a 
great  many  nuclei.  The  sarcomata  are  very  vascular. 
There  is  a  variety  of  sarcoma,  characterized  by  an 
excessive  development  of  blood  vessels,  called  angeio- 
sarcoma,  or  erectile  sarcoma.  Sometimes  fat  cells 
grow  out  of  the  other  cells,  producing  fatty  degenera- 
tion, which  is  more  apt  to  take  place  in  spindle  than 
in  round  or  giant-cell  sarcoma.  It  differs  in  malignity 
in  the  character  of  the  cell,  the  round  cell  being 
more,  the  spindle  cell  less,  and  the  giant  cell  least 
malignant.  It  has  a  progressive  tendency  and,  if 
allowed  to  remain,  and  neither  fatty  nor  calcareous 
degeneration  occurs,  it  destroys  life.  The  method 
of  recurrence  of  this  tumor,  after  extirpation,  con- 
stitutes one  of  the  observed  differences  between  it 
and  carcinoma.  A  cancer,  when  removed,  recurs,  but 
not  necessarily  on  the  site  of  the  old  tumor;  whereas 


—  127   — 

sarcoma  recurs  nearly  always  in  the  exact  site  of  the 
original  tumor.  In  carcinoma  it  is  more,  apt  to  occur 
in  what  is  termed  the  secondary  form,  by  making  its 
appearance  in  some  of  the  internal  organs,  the  nearest 
lymphatic  gland,  or  even  some  point  quite  removed 
from  the  original  infection.  The  lymphatic  glands 
are  not  always  affected,  except  those  in  the  path  of 
circulation  from  the  tumor  to  the  center  of  the  lymph 
system;  there  is  no  "  cancer  juice."  The  sarcomatous 
cells  also  form  continuous  portions  of  tissue;  whereas 
in  carcinoma  the  reverse  of  all  this  occurs.      There  is 


Fig,  6. — Small  round-celled   sarcoma,      (x  300,   after  Wood- 
head). 

a.  Small  round  cells,  with  nuclei  and  nucleoli. 

b.  Flattened  spindle  cells  forming  walls  of  embryonic 
blood  vessels. 

great  pain;  the  lymphatic  glands  are    affected;   and 
there  is  "cancer  juice."     The  cells  do  not  form  part 


—    128    — 

of  the  tissue.  There  is  a  difference  in  the  malignancy 
of  sarcoma,  according  to  its  site.  Sarcoma  of  the  tes- 
ticles, for  some  unknown  reason,  is  more  liable  to 
destroy  life  than  sarcoma  of  the  ovary;  why  this 
should  be,  is  not  understood.  Then  we  have  sarcoma 
of  the  hand,  which  will  surely  destroy  life  unless  am- 
putation is  performed.  A  medical  officer  of  the  army 
called  upon  me  some  years  ago,  having  a  diffuse 
swelling  or  thickening  of  the  hand.     It  showed  more 


Fig.  7. — Giant-cell  sarcoma     (x  400,  after  D.  J.  Hamilton.) 

a.  Spindle-cell  basis  round  the  giant-cell. 

b.  Giant  cell,  containing  many  nuclei. 

c.  Vacuole  in  a  giant  cell. 


129    — 

externally  than  in  the  palm.  It  was  discolored,  but 
painless,  and  I  regarded  it  as  not  carcinomatous.  A 
puncture  was  made,  and  some  of  the  fluid  which  flowed 
out  was  submitted  by  the  officer  to  the  late  Surgeon 
Woodward  for  microscopical  examination.     He  found 


Fig.  8. — Small    spindle-celled  sarcoma,     (x  300,  after  Wood- 
head.) 

a.  Well  formed  spindle  cells. 

b.  Elongated  spindles  bounding  one  of  the  blood  ves- 

sels. 

c.  Embryonic  blood  vessel  cut  transversely. 

d.  Transverse  section  of  spindle  cell.     (This  transverse 

section  with  the  section  of  the  nucleus  must  nat 
be  mistaken  for  the  round  cell.) 

9  WW 


—   13°  — 
the  round-celled  sarcoma.      The  patient  was  then  on 
I'eave  of  absence,  and  died   about  four  months  there- 
after.    The  swelling  was  not  at  that  time  very  great, 
and  there  was  no  pain. 

There  is  a  melanotic  or  pigment  sarcoma,  having 
its  seat  mostly  in  the  skin,  and  in  the  choroid  of  the 
eye — sometimes  in  the  lymphatic  glands,  but  it  may 
be  found  elsewhere.  A  case  of  melanotic  cysto-sar- 
eoma  was  under  my  care  a  few  years  ago,  in  which 
the  tumor  recurred  three  times  after  extirpation.  In 
this  case  the  mammary  gland  of  the  right  side  was 
alone  affected,  and  the  tumor  recurred  at  the  site  of 
operation.  The  patient  finally'died  with  all  the  symp- 
toms of  general  anaemia  accompanying  the  cancerous 
cachexia. 

The  giant-cell  sarcoma,  or  so-called  myeloid,  has 
its  common  seat  in  the  bone,  although  it  may  appear 
in  the  mammary  gland.  There  is  a  characteristic 
difference  between  all  the  sarcomata  and  adenomata 
©f  the  mammary  gland.  In  sarcoma,  upon  section 
the  cut  surface  will  present  little]  pink  vascular  points 
©f  different  shades  of  color,  which  afford  a  pretty 
ready  coarse  means  of  distinguishing  sarcoma  from 
adenoma  by  the  eye,  for  in  adenoma,  on  the  contrary, 
there  is  only  the  usual  appearance  of  glandular  struc- 
ture. 

The  following  table  from  Woodhead  will  be  useful 
to  you  in  making  your  comparison  between  sarcoma 
and  carcinoma: 


—  131  — 

DIFFERENTIAL    DIAGNOSIS    (fROM    WOODHEAD). 


CARCINOMA. 


SARCOMA. 

s.  Origin   Entirely  mesoblastic.      Meso-    and     epi-     or 

hypo-blastastic. 

2.  Stroma Intercelluar.       Does    Forms  alveoli,  which 

not    form    alveoli        communicate   with 
only.  one    another,     and 

surround  masses  of 
cells. 


3.  Cells. 


.Granulation   tissue  or  Epithelial,  shape  and 

embryonic  cells,  not  size  various.     Dis- 

epithelial  (shape  va-  tinct  nuclei  and  nu- 

rious).  cleoli. 


4.  Intercellu-  ) 

lar    sub-  >•  Present, 
stance.       ) 

5.  Vessels Embryonic  in  charac- 

ter. In  contact  with 
the  special  cells  of 
which  tumor  is  com- 
posed, and  formed 
by  modification  of 
them. 

■6.  Spread By  blood-vessels. 


7.   Malignancy. Great. 


Absent,  or  merely 
fluid. 

Well  developed,  en- 
tirely contained  in 
the  walls  of  the  al- 
veoli. Not  in  con- 
tact with  the  cells, 
except  in  very  rare 
cases. 

By  lymphatics,  ex- 
cept in  the  later 
stages,  when  they 
may  also  spread  by 
blood-vessels  and 
then  very  rapidly. 

Greater. 


Treatment:  Whenever  possible,  it  should  be  ex- 
tirpated early.  You  must  not  allow  your  patient  to 
take  any  chance  as  to  the  malignancy  of  the  disease, 


—    132    — 

bearing  in  mind  that  unless  fatty  degeneration,  calci- 
fication, or  ossification  occurs,  the  disease  will  steadily 
progress,  and  the  life  of  the  patient  be  destroyed. 
When  the  bone  is  involved,  constituting  osseous  sar- 
coma, amputation  will  almost  invariably  be  required. 
In  regard  to  amputation,  the  rule  is  to  amputate  the 
whole  bone  involved,  or  the  tumor  will  reappear  in  * 
the  stump.  Careful  examinations  should  be  frequently 
made  after  operation,  and  on  the  appearance  of  any 
neoplasm  it  should  be  promptly  extirpated,  passing 
the  knife  in  healthy  tissues. 


LECTURE    XII. 

PROLIFERATION  TUMORS,  CONTINUED. 


CARCINOMA. 


I  have  long  been  of  opinion  that  the  true  origin 
of  carcinoma  must  be  found  through  a  study  of  cases 
in  their  incipiency.  We  usually  see  carcinoma  after 
it  is  fully  developed,  but  I  firmly  believe  that  some 
one  having  leisure  and  opportunity  will  make  ex- 
amination of  a  sufficient  number  of  cases  to  establish 
the  character  and  conditions  of  this  neoplasm  from 
the  first  point  of  departure  from  the  normal  structure 
to  the  completed  carcinoma. 

We  will  now  take  up  the  study  of  the  last  remain- 
ing variety  of  Class  4— carcinoma,  and  the  cancerous 
tumors.  The  term  cancer  is  one  that  has  -been  ap- 
plied to  so  many  different  forms  of  tissue  and  so 
many  different  forms  of  tumor  as  to  have  lost  its 
significance  in  a  scientific  sense.  Sometimes  adenoma 
(which,  as  you  know,  is  a  simple  hyperplasia  of  the 
glandular  tissue)  is  called  cancer,  because  it  occasion- 
ally assumes  cancerous  degeneration.  Sarcoma  has 
also  been  called  a  cancer,  hence  the  present  tendency 
among  pathologists  to  discard  the  term  cancer,  and 
employ  always  the  word  carcinoma.  Carcinoma  pre- 
vails in  all  parts  of  the  world;  there  is  no  geographical 
region  exempt,  nor  can  you  find  any  particular  region 
that  is  specially  favorable  to  the  formation  of  cancer. 


—  J34  — 
In  England  alone,  from  1838  to  1842,  there  were 
11,662  persons  who  died  from  carcinoma.  Of  these, 
8,746  were  women  and  2,916  men.  In  the  U.  S. 
census  of  1870  there  were  recorded  6,224  deaths  from^ 
carcinoma;  of  these,  3,923  were  females  and  2,301 
males;  making  about  one  in  thirt}^  in  that  census  re- 
port. The  report  of  the  Census  Bureau  for  i88a 
shows  13,068  deaths  from  carcinoma,  of  which  4,875, 
were  males  and  8,195  females. 

In  the  Marine  Hospital  reports,  the  proportion  of 
deaths  from  carcinoma  is  i  in  70,  occurring  among 
adult  males  exclusively.  It  is  more  prevalent  in. 
women  than  in  men,  because  the  larger  number  are 
found  in  the  mammary  glands  and  the  uterus;  so 
when  you  exclude  carcinoma  of  the  mammary  gland 
and  of  the  uterus,  the  death-rate  is  reduced  very 
materially.  There  have  been  at  different  times  great 
disputes  as  to  the  particular  cancer  cell  that  is  to  be 
found  in  each  special  variety  of  carcinoma.  There  is 
no  longer  belief  in  any  specific  cancer  cell;  that  is  to 
say,  the  cancer  is  now  believed  to  be  a  growth  of 
epithelial  tissue  which  has  grown  out  of  place.  Yoa 
will  not  be  far  wrong  if  you  view  all  carcinomata  as 
one  disease,  the  alleged  subdivisions  as  many  of  them 
arbitrary,  and  all  of  them  founded  on  chnical 
differences,  some  01  which  may  be  accidental. 
Hamilton's  (of  Aberdeen)  definition  of  cancer  is  "a 
neoplasm  formed  of  any  tissue  whose  fibrous  inter- 
spaces   and    lymphatic    vessels    are   infiltrated    with 


—  135  — 

actively  proliferating  epithelial  cells."  Carcinoma 
may  be  developed  in  any  part  which  has  epithelial 
tissues,  or  any  organ  of  the  body  which  has  epithelial 
tissue  in  its  substance.  Now,  we  distinguish  carcino- 
mata  in  general  from  other  tumors  of  the  body  by 
what  we  term  the^alveolar  structure,  wherein  the  so- 
called  cavity  or  cell  is  formed.  I  show  you  here  a 
diagram  from  Cornil  and  Ranvier,  which  exhibits  this 
alveolar  structure  very  clearly.  We  find  that  these 
alveolar  spaces  are  filled  with   epithelial  cell  infiltra- 


Yic,  g. — Stroma  of  Carcinoma,  lying  In  which  are  the  alveoli 
from  which  the  epithelial  cells  have  been  removed  by 
penciling,     (x  300,  after  Cornil  and  Ranvier.) 


Fig. 


s.  I 
r.m. 


/• 


lo. — Diagram    to    represent    changes   which  take  place 
during   the   invasion  of  connective  tissue  by  epithelial 
columns.     (After  Woodhead.) 
Stratum  corneum,  or  horny  layer  of  cuticle. 
Stratum  lucidum — s  gr. — Stratum  granulosum. 
Rete    Malpighii.      b    Superficial    more    flattened    cells, 

beneath  which  are  the  well-formed  prickle  cells. 
Layer  of  columnar  or  germinal  cells. 
Epithelium  at  normal  level. 

'  e.  Epithelial  bands  passing  between  the  papillae. 
Normal  connective  tissue  papillae. 
Cellular  and  vascular  connective  tissue. 
Blood-vessels. 


—  137  — 
tions.  I  say  infiltrated,  because  they  are  not  natur- 
ally there;  they  do  not  belong  to  the  part.  All  these 
cells  have  nuclei;  not,  however,  in  the  same  manner 
as  the  giant-celled  sarcoma.  There  is  usually  a  single 
nucleus  to  each  cell.  This  alveolar  structure  (pure 
fibrous  tissue)  constitutes  the  stroma  of  the  cancer. 
It  contains  the  blood-vessels,  and  grows  at  an  equal 
pace  with  the  young  epithelial  cells.  These  cells 
keep  pushing  on,  and  extending  into  the  tissues,  form- 
ing cylinders,  or  what  the  charlatan  cancer-men  call 
the  "  roots  "  of  the  cancer.  This  is  simply  a  prolong- 
ation. In  these  structures  there  is  no  capsular  or 
limiting  membrane.  In  speaking  of  lipoma  I  told 
you  that  all  fatty  tumors,  hygromata  and  cysts,  were 
encapsulated  by  dense  fibrous  connective  tissue,  and 
this  when  cut  down  upon  would  show  a  white  shining 
surface,  and  that  the  tumor  itself  does  not  directly 
enter  the  tissue.  Now  in  carcinomata  there  is  no 
capsule.  These  prolongations  enter  directly  into  the 
tissue.  At  the  outset  all  these  growths  of  carcinom- 
ata are  distinctly  local.  That  is  not  the  case  later 
on,  when  we  shall  speak  of  cachexia.  All  the  carci- 
nomata are  malignant,  for  they  sooner  or  later  de- 
stroy life.  The  degree  of  malignancy  is  different  in 
the  different  forms  of  tumor,  and  of  that  I  will  speak 
in  giving  the  varieties. 

Although  I  say  that  it  is  not  primarily  a  disease 
■of  the  blood,  it  is  a  well  known  clinical  fact  that  the 
child  of  a  cancerous  parent  has  a  predisposition  to 


-  138  - 

the  formation  of  cancer — that  in  a  family  where  one 
brother  or  sister  has  a  cancer  there  may  be  others 
similarly  affected.  At  first  blush  you  will  say  that 
is  an  evidence  of  blood  infection;  but  if  you  recall 
what  I  said  in  my  opening  lecture,  about  the  theory 
of  Cohnheim  that  all  tumors  are  congenital,  you  will 
see  what  is  now  meant  by  the  term  hereditary,  viz., 
that  there  is  some  local  defect  causing  an  atypical 
cell,  which  may  remain  dormant  or  latent.  Our  class- 
ification recognizes  seven  varieties  of  carcinomata, 
but  at  least  four  of  them  should  not  be  so  classed; 
thus,  the  medullary,  or  encephaloid,  is  a  carcinoma 
like  the  type,  except  that  the  stroma  is  very  slight, 
the  alveoli  large,  and  the  cells  are  greatly  increased. 
The  melanotic  carcinomata  differ  only  in  having  the 
pigment  or  melanine.  It  is  doubtful  if  a  true  carci- 
noma of  bone  exists.  There  is  of  course  an  osteoid 
sarcoma,  but  as  there  are  no  bone  cells  in  it,  it  is  a 
sarcoma  springing  from  the  periosteum. 

The  colloid  carcinoma  consists  in  distinct  alveoli 
filled  with  a  gelatinous  mucoid  mass,  especially  com- 
mon in  the  ovary  and  the  abdominal  cavity. 

In  epithelioma  we  have  the  true  carcinoma  which 
constitutes  the  type— epithelial  cancer.  Epithelioma 
is  slower  in  growth  than  the  scirrhus,  and  in  certain 
circumstances,  when  extirpated  early,  does  not  recur. 
Indeed,  it  is  probable  that  none  of  the  carcinomata 
would  recur  after  extirpation  if  it  were  possible  to 
make    a    diagnosis    and  operate  upon  them  in  their 


—   139  — 

incipiency.     Epithelioma  of  the  h'p  may  be  taken  as  a 
type  of  the  class.     It  is  one  most  amenable  to  treat- 


FlG.  II. — Case  of  epithelioma  growing  from  a  cicatrix. 
From  a  patient  at  Providence  Hospital. 


—  140  — 

ment.  The  disease  occurs  in  the  beginning  as  a 
small  crack  or  fissure  in  the  lip,  and  gradually  ex- 
tends until  the  whole  lip,  and  sometimes  cheek,  is  in- 
volved. It  is  at  first  not  very  painful,  but  becomes 
so  as  the  disease  progresses;  haemorrhages  are  fre- 
quent. After  an  apparently  thorough  extirpation  it 
may  recur,  but  always  at,  or  adjoining,  the  original 
site;  whereas  in  the  scirrhus  the  recurrence  may  be 
in  the  nearest  lymphatic  gland,  or  in  some  internal 
organ.  It  should  be  an  invariable  rule  in  extirpation 
of  all  the  carcinomata,  to  keep  clear  of  the  diseased 
structure,  carrying  the  knife  in  sound  tissues.  Lack 
of  this  precaution  will  render  this  operation  unavail- 
ing in  preventing  the  recurrence  of  the  disease. 

Scirrhus.  In  this  form  of  carcinoma  the  stroma 
is  very  dense  and  firm,  and  the  alveoli  small  and  com- 
pressed. I  will  describe  a  typical  case:  A  female 
patient  will  come  to  you  complaining  of  sharp  lan- 
cinating pain  in  the  breast;  not  infrequently  she 
will  have  a  history  of  some  injury,  such  as  striking 
the  breast  on  a  sharp  corner,  or  being  accidentally 
struck  with  the  elbow,  etc.,  etc.  At  any  rate,  on  exam- 
ination of  the  breast,  if  the  case  be  not  far  advanced, 
you  find  a  painful  swelling  just  beneath  the  nipple, 
or  at  one  side  of  it.  This  is  at  first  moveable,  but 
as  the  case  progresses  the  nipple  becomes  retracted 
more  and  more,  the  tumor  rapidly  grows  larger  and 
firmly  attached  to  the  periosteum  of  the  ribs;  the 
glands  in  the  axilla  become  swollen,  and  the  patient's 


—   141   — 

sufferings  greatly  increase.  She  will  then  have  the 
cachectic  appearance,  the  general  appearance  of 
anaemia;    and   the  more  malignant  the    growth,   the 


Fig.   12. — Case  of  scirrhus  of  the  neck.     From  a  sailor 
in  Providence  Hospital 


142    — 

more  characteristic  the  cachexia.  When  the  carci- 
noma has  grown  so  that  the  entire  mammary  gTand 
has  become  involved,  the  skin  over  the  tumor  usually 
becomes  infiltrated,  ulceration  sets  in,  and  the  patient 
speedily  dies.  This  is  the  usual  course  of  this  form 
of  carcinoma.  In  other  organs  the  symptoms,  of 
course,  vary  according  to  the  location  and  the  physio- 
logical functions  of  the  organs  involved.  These  will 
all  be  separately  considered  in  my  forthcoming  vol- 
ume on  Tumors  of  the  Regions,  in  which  the  diag- 
nostic points  will  be  fully  considered.  It  is  proposed 
to  fully  illustrate  the  work,  and  describe  the  respec- 
tive operations  necessary  for  their  removal,  in  detail.  "^ 
I  have  only  glanced  at  the  general  principles  un- 
derlying our  knowledge  of  morbid  growths,  and,  as 
science  never  stands  still,  you  must  constantly  study 
if  you  would  keep  abreast  of  your  fellows. 


INDEX. 


A.  Page. 

Acne  pancreaticus 56 

Adenoma loi 

Angeioma 104 

Angeio-lithic  sarcoma 95 

Appliances  for  examination  of  tumors i 

B. 

Barbadoes  leg 74 

Barren  cyst 41 

Blood  tumor 30 

Bronchocele,  cystic 51,  54 

C. 

Carcinoma 133 

,  definition  of 134 

,  how  distinguished 134 

Causes  of  scrotal  hsematoma 36 

Chondroma 91 

Classes  of  tumors,  tables  of 24-  29 

Classification  of  tumors 21 

,  Virchow's 22 

Cochin-China  leg 74 

Colloid  carcinoma 136 

Color  of  tumors  in  diagnosis 15 

Comedones 55 

Condyloma 107-108 

Cyst,  dermoid 104 

Cystic  bronchocele 51,  53 

Cystiform  haematoma 36 

Cysts 46 

,  bony 47 


—   144  — 

Page . 

Cysis,  deniigerous 48 

,  diagnosis  of , 49 

,  ovarian 58 

— diagnosis  of 60 

— treatment  of 63 

,  parasitic 66 

,  parovarian 55,  63,  64 

— treatment  of 49 

D. 

Dermoid  cyst 104 

Desmoid  tumor 72 

Diagnosis,  color  of  tumors  in 15 

of  cysts 49 

myoma 97 

myxoma 90 

ovarian  cysts • 60 

pelvic  haematoma 32 

scrotal  haematoma 37,  38 

,  size  of  tumors  in 14 

of  tumors .■ 14 

Differential  diagnosis  between  sarcoma  and  carcinoma  . .  .  131 

Dropsy  of  bursae  mucosae 43 

E. 

Ecchondroma  91 

Elephantiasis 73 

Arabum 74 

Graecorum 74 

Enchondroma 91 

Epithelioma 138 

Epulis 81 

Exostosis 94 

Extravasation  tumors , 30 

Exudation  tumors 40 


—  145  — 

F.  Page. 

Farcy 122 

Fibroma 71 

Fibro-neuromata 73 

Fibrous  epulis 81 

Framboesia 120 

G. 

Galactocele 7° 

Ganglion 43 

,  treatment  of 44 

General  considerations 7 

Glanders 122 

,  treatment  of 123 

Glioma no 

Granulation  tumors 115 

Gumma ii5>   ii7 

,  treatment  of 118 

H. 

Haematoma 30 

auris 30 

,  cystiform 36,  39 

,  parenchymatous 40 

,  pelvic 30 

— diagnosis  of 32 

— symptoms  of 30-34 

— treatment  of 34 

,  polypoid 40 

,  pudendal 35 

,  scrotal 37 

— causes  of 36 

— diagnosis  of 37-38 

— treatment  of 38 

Haematometra 31,  32 

Hodgkin's  disease 124 

10   WW 


—   146  — 

Page. 

Housemaid's  knee 42 

Hydrops  neonatorum 56 

Hygroma / 41 

,  proliferating 41 

— treatment  of 42 

Hyperostosis 94 

K. 

Keloid 83 

L. 

Leiomyoma 96 

Lepra  Arabum 118 

Leprosy 118 

,  differential  diagnosis  of,  from  elephantiasis 75 

,  symptoms  of 119 

,  treatment  of ; . . . .  120 

Lipoma 86 

,  treatment  of 89 

Lupus 115 

,  treatment  of 117 

Lymphatic  adenoma 124 

Lymphoma , 125 

M. 

Medullary  cancer 138 

Melanoma 95 

Melanotic  cancer 130,  138 

Meliceris 45 

Molluscum  contagiosum 103 

fibrosum 78 

Mucocele 68 

Mucous  polypus loi 

tubercle 107 

Miiller,  law  of 18,  19 

Myofibroma 9^ 


—  147  — 

Page. 

Myoma 96 

,  diagnosis  of 97 

,  treatment  of 99 

Myxoedena  following  goitre 53 

Myxoma 89 

,  diagnosis  of 90 

N. 

Neuroma 99 

Nomenclature  of  tumors it 

O. 

Odontoma. 95 

Origin  of  tumors. 18 

Osteoid  ecchondroma 92 

Osteoma 94 

Osteophyte 94 

Ovarian  cysts '. 58 

,  diagnosis  of 60 

,  treatment  of j 63 

P. 

Parasitic  cysts '. 66 

Parenchymatous  hsematoma 40 

Parovarian  cysts 55,  63,  64 

Papilloma 107 

Pelvic  hsematoma 30 

,  diagnosis  of 32 

,  symptoms  of 30,  34 

,  treatment  of 34 

Polypoid  haematoma 40 

Polypus,  mucous loi 

Proliferating  hygroma 41 

,  treatment  of 42 

Proliferation  tumors 71 


—  i4»  — 

Page. 

Psammoma qS 

Pudendal  haematoma 35 

R. 

Ranula 66 

,  origin  of  name 66 

,  treatment  of 67 

Retention  tumors 46 

Rhabdomyoma 96 

S. 

Sarcoma , .  1 25 

,  treatment  of • 131 

Scirrhus 140 

Scrotal  hasmatoma 37 

,  causes  of 36 

,  diagnosis  of 37-38 

•          ,  treatment  of 38 

Sebaceous  cyst 68 

Size  of  tumors  in  diagnosis 14 

Spedalsky 74 

Symptoms  of  leprosy 119 

T. 

Tables  of  classes  of  tumors 24-  29 

Teleangeiectasis 96,  97 

Thrombus  of  the  vulva 35 

Tic-douloureux  ....      loi 

Transudation  tumors 40 

Treatment  of  cysts 49 

ganglion 44 

glanders 123 

gumma ri8 

leprosy 120 

lipoma 89 


—  149  — 

Page. 

Treatment  of  lupus 117 

ovarian  cysts  . . .  .■ 63 

pelvic  haematoma 34 

proliferating  hygroma 42 

ranula 67 

sarcoma 131 

scrotal  haematoma 38 

urethral  caruncle no 

yaws 121 

Tumors,  classification  of 21 

,  color  of  in  diagnosis 15 

,  combination 18 

,  definition  of 7 

,  diagnosis  of g 

,  extravasation 30 

,  exudation 40 

,  granulation 115 

,  origin  of . . .    18 

,  proliferation 71 

,  rapid  growth  of 12 

,  retention 46 

,  size  of  in  diagnosis 14 

,  tables  of  classes  of . .  .24-29 

,  transudation 40 

U. 

Urethral  caruncle 107,  109 

,  treatment  of no 

V. 

Verruca  filiformis 107 

plana 107 

senilis 107 

Vulva,  thrombus  of 35 


—  15°  — 

W.  Page. 

Warts .• 99-107 

Watery  cysts 41 

Wen 68 

Y. 

Yaws 1 20 

,  treatment  of 121 


How  to  Administer  Iron. 


It  is  generally  conceded  that  the  officinal  tincture 
of  chloride  of  iron  is  the  most  valuable  of  the  iron 
preparations  therapeutically.  The  practical  difficulties 
attending  its  administration  for  a  length  of  time  have 
been  its  disagreeably  astringent  taste,  its  corrosive 
action  on  the  teeth,  and  its  constipating  action. 

Dr.  G.  W.  Weld's  extensive  experience  in  the 
practice  of  dentistry  led  him  to  recognize  the  virtues 
of  the  tincture  of  the  chloride  of  iron  as  a  stimulant 
resource  for  patients  after  the  strain  of  the  dentist's 
work.  Repeated  experiments  to  obtain  a  formula  free 
from  the  objectionable  features  resulted  in  the  prepara- 
tion of  a  highly  palatable  syrup,  with  all  the  therapeu- 
tic efficacy  preserved.  This  has  been  extensively  tested 
and  placed  in  the  hands  of  Parke,  Davis  &  Co.  for 
manufacture,  who  strongly  recommend  it  to  the  medi- 
cal profession  for  trial.  Being  prepared  after  Dr. 
Weld's  formula,  it  is  entitled  Weld's  Syrup  of  Iron 
Chloride  (P.,  D.  &  Co.'s).  It  is  believed  it  will  effect  a 
revolution  in  iron  administration. 

Samples  will  be  sent  on  receipt  of  request  to 
physicians  who  indicate  their  willingness  to  pay  ex- 
press charges. 

PARKE,  DAVIS  &  CO., 

Detroit,  New  York,  and  Kansas  City. 


ByisE)CTm  eFpa5ucATioN3 

—  OF  - 

GEORGE    S.    DAVIS,    Publislier. 

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A.    MontJnly  Journal  of   Physiological  and    Clinical  Thepapeutics. 

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We  have  made  a  new  departure  in  the  publication  of  medical  books.  As  you 
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SERIES  I. 


Inhalers.  Inhalations  and  Inhalants. 
By  Beverley  Robinson,  M.  D. 

The  Use  of  Electricity  in  the  Removal  of 
Superfluous  Hair  and  the  Treatment  of 
Various  Facial  Blemishes. 
By  Geo.  Henry  Fox,  M.  D. 
New  Medications,  Vol.  I. 

By  Dujardin-Beaumetz,  M.  D. 

New  Medications,  Vol.  II. 

By  Dujardin-Beaumetz,  M.  D. 

The  Modern  Treatment  of  Ear  Diseases. 
By  Samuel  Sexton,  M.  D. 

The  Modern  Treatment  of  Eczema. 
By  Henry  G.  Piffard,  M.  D. 


Antiseptic  Midwifery.  ,   „ 

By  Henry  J.  Garrigues,  M.  D. 
On  the  Determination  of  the  Necessity  for 
Wearing  Glasses. 

By  D.  B.  St.  John  Roosa,  M.  D. 
The  Physiological, Pathological  and  Ther- 
apeutic Effects  of  Compressed  Air. 

By  Andrew  H.  Smith,  M.  D. 
GranularLidsandContagiousOphthalmla. 

By  W.  F.  Mittendorf,  M.  D. 
Practical  Bacteriology. 

ByThomas  E.  Satterthwaite,  M   D. 
Pregnancy,    Parturition,    the     Puerperal 
State  and  their  Complications. 

By  Paul  F.  Mundg,  M.  D. 


SERIES   II. 


The  Diagnosis  and  Treatment  of  Haem- 
orrhoids 
By  Chas.  B.  Kelsey,  M.  D. 

Diseases  of  the  Heart,  Vol.  I. 
■    By  Dujardin-Beaumetz,  M.  D. 

Diseases  of  the  Heart,  Vol.  II. 
By  Dujardin-Beaumetz,  M.  D. 

The  Modern  Treatment  of  Diarrhoea  and 
Dysentery. 

By  A.  B.  Palmer,  M.  D. 
Intestinal  Diseases  of  Children,  Vol.  I. 

By  A.  Jacobi,  M.  D. 
Intestinal  Diseases  of  Children,  Vol.  M. 

By  A.  Jacobi,  M.  L». 


The  Modern  Treatment  of  Headaches. 
By  Allan  McLane  Hamilton,  M.  D. 

The  Modern  Treatment  of  Pleurisy  and 
Pneumonia. 

By  G.  M.  Garland,  M.  D. 
Diseases  of  the  Male  Urethra. 

By  Fessenden  N.  Otis,  M.  D. 
The  Disorders  of  Menstruation. 

By  Edward  W.  Jenks,  M.  D. 
The  Infectious  Diseases,  Vol.  I. 

By  Karl  Liebermeister. 

The  Infectious  Diseases,  Vol.  11. 
By  Karl  Liebermeister. 


SERIES   III. 


Abdominal  Surgery. 

By  Hal  C.  Wyman,  M.  D. 

Diseases  of  the  Liver- 

By  Dujardin-Beaumetz,  M.  D. 

Hysteria  and  Epilepsy. 

By  J.  Leonard  Corning,  M.  D. 

Diseases  of  the  Kidney. 

By  Dujardin-Beaumetz,  M.  D. 

The  Theory  and  Practice  of  the  Ophthal- 
moscope. 

By  J.  Herbert  Claiborne,  Jr.,  M.  D. 

Modern  Treatment  of  Bright's  Disease. 
By  Alfred  L.  Loomis,  M.  D. 


Clinical  Lectures  on  Certain  Diseases  of 
Nervous  System. 

By  Prof.  J.  M.  Charcot,  M.  D. 
The  Radical  Cure  of  Hernia. 

By  Henry  O.  Marcy,  A.  M.,  M.  D., 
L.  L.  D. 
Spinal  Irritation. 

By  William  A.  Hammond,  M.  D. 
Dyspepsia. 

By  Frank  Woodbury,  M.  D. 
TheTreatpientof  the  Morphia  Habit. 

By  Erlenmeyer. 
The  Etiology,  Diagnosis  and  Therapy  of 
Tuberculosis. 

By  Prof.  H.  von  Ziemssen. 


SERIES  lY. 


Nervous  Syphilis. 

By  H.  C.  Wood,  M.  D. 

Education  and  Culture  as  correlated  to 
the  Health  and  Diseases  of  Women. 
By  A.  J.  C.Skene,  M.  D. 

Diabetes.  _ 

By  A.  H.  Smith,  M.  p. 

A  Treatise  on  Fractures. 

By  Armand  Despres,  M.  D. 

Some  Majorand  Minor  Fallacies  concern- 
ing Syphilis. 

By  E.  L.  Keyes,  M  .D. 
Hypodermic  Medication. 

By  Bourneville  and  Bricon. 


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sis. 

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vous Disease. 

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Lessons    In    tiie    Diagnosis    and 
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tate. 

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Artificial  Anaesthesia  and  Anaes- 
thetics. 

By  DeForest  Willard,  M.  D.,  and  Dr. 
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Cancer. 

By  Daniel  Lewis,  M.  D. 

The  Modern  Treatment  of  Hip  Dis- 
ease. 

By  Charles  F.  Stillman,  M.  D. 

Insomnia  and  Hypnotics. 

By  Germain  S6e . 

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